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COPYRIGHT DEPOSIT. 



EXERCISE 




IN 



EDUCATION AND MEDICINE 



BY 

R. TAIT McKENZIE, B. A., M. D. 

Professor of Physical Education and Director of the Department, University of Pennsyl- 
vania; Fellow of the College of Physicians of Philadelphia and of the American Academy 
of Physical Education; President of the American Physical Education Association, 1913- 
1915; President of the Society of Directors of Physical Education in Colleges, 1912; Some- 
time Lecturer in Anatomy and Medical Director of Physical Training at McGill University ; 
Lecturer in Artistic Anatomy, Montreal Art Association, Harvard Summer School, and 
Olympic Lecture Course, St. Louis, 1904 ; M. P. E. Springfield College 



SECOND EDITION, THOROUGHLY REVISED 



WITH 478 ILLUSTRATIONS 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

19 15 






Copyright, igog, by W. B. Saunders Company. Reprinted February, igio/ 
Revised, entirely reset, reprinted, and recopyrighted June, igis , 



Copyright, igis, by W. B. Saunders Company 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHJA 



/^, 



$i? 



^Wi- I 1915 

'CI,A4(ir)529 






"Man is the sum of his movements." — F. H. Robertson. 

"That which those who minnow wheat do for it, gymnastic exercises accom- 
plish in our bodies for us." — Solon {Dialogues of Lucian). 

"Intrepidity, contempt of softness, surrender of private interests, obedience 
to command, must remain the rock upon which states are built." — William James. 

"It is to be considered that some medicines may require exercise in order 
to enhance their virtues or remove some inconveniences attending their operation. 
Exercise, in such cases, is like the just and exact incubation to the egg ; that 
which animates the drug and gives it power to produce the desired effect." — 
Fuller. 



\ 



PREFACE TO THE SECOND EDITION 



During the four years since the publication of this book 
physical education has changed ground so rapidly that an 
almost complete rewriting of the work seems necessary to keep 
the reader in touch with recent progress along old lines of in- 
vestigation and the development of ideas that are new. 

Unusual activity in the physiology of exercise has thrown 
such a flood of new light on the effects of muscular work on the 
heart, vessels, and excretory organs that it has been necessary to 
expand the single chapter on Physiology into four. 

The increasing recognition of athletic sports by the school 
and the college makes them a potent factor in education, and the 
boy's school day is more and more approaching that of the 
Athenian lad, with its intimate blending of mental and physical 
training. 

The supervision and organization of play under school and 
municipal control is making necessary a new profession, in 
which the study of psychology and physiology takes an impor- 
tant place. 

The eurythmics of Jacques Dalcroze, widely popularized in 
Europe, introduce a new note into physical education that de- 
mands notice if this contribution is to be saved from the over- 
exploitation by the partiality inspired, which made the name of 
Delsarte a byword forty years ago, and more recently killed the 
interest in jiu jitsu. 

7 



5 PREFACE TO THE SECOND EDITION 

The chapters on Medical Gymnastic Movements and Mas- 
sage have been expanded and rearranged. New chapters have 
been added on respiratory gymnastics, the treatment of viscerop- 
tosis, and functional disorders of the nervous system. 

Where possible, acknowledgment is made in quoting the 
work of others, to whom I herewith extend my thanks for the 
many courtesies received, but for a more complete bibliography 
on physical education I would refer the reader to "Physical 
Training BibKography," by Dr. James Huff McCurdy, brought 
up to 191 1 by Dwight F. Bridges, and brought up to date every 
year by G. B. Affleck, and pubhshed in the "American Physical 
Education Review." 

For the most complete list of works on medical gymnastics 

one cannot do better than consult the "Bibhographic Gym- 

nastica Medica," by Edgar F. Cyriax, of London; also brought 

up to date yearly in the "American Physical Education 

Review." 

R. T. M. 

Philadelphia, Pa., 
June, 1915. 



PREFACE TO THE FIRST EDITION 



The following pages are addressed to students and practi- 
tioners of physical training; to teachers of the youth; to stu- 
dents of medicine and to its practitioners, with the purpose to 
give a comprehensive view of the space exercise should hold in 
a complete scheme of education and in the treatment of abnor- 
mal or diseased conditions. 

The recognition of physical education by teachers has been 
retarded by dabblers and self-elected professors of one or other 
systems, whose extravagant claims have done much to obscure 
the real educational value of neuromuscular training; for the 
result of physiologic research in the growth and development 
of the nervous system is just beginning to be applied in the 
classification and design of exercise, to harmonize it with the 
conclusions of proved science. 

Exercise has so many points of contact with education, it is 
so intricately related to mental, moral, and social training, each 
of which alone is so partial and incomplete, that the progressive 
educationalist is now compelled to study its bearing on all three. 

It is of vital importance that the student of physical training 
should have a broad and catholic foundation on which to build 
the structure of his experience, and that he shall consider and 
balance the merits and limitations of systems and ideas coming 
from diverse lands. The normal schools and colleges of physical 
training are lengthening their courses and broadening their cur- 
riculum to meet this increasing need, and, with more thoroughly 
educated instructors, there will be less seen of a certain super- 
ciliousness with which the whole subject is regarded by some 
otherwise well-informed physicians. 



lO PREFACE TO THE FIRST EDITION 

The progress of medxal science has been most notable in the 
great questions of national health and prosperity involved in the 
feeding, housing, and exercise of the people. School boards are 
appealing for medical inspection of the children to discover cor- 
rectable defects and to prevent the spread of disease. The 
pernicious influence of indoor life on growth has been proved,- 
and measures arc now taken to remedy it by exercise and play; 
city slums are replaced by playgrounds, colleges and universities 
are placing on their curriculum instruction in physical education, 
both practical and theoretical, since the necessity for exact know- 
ledge of the physical characteristics which differentiate the child 
from the youth, and both from the adult, has become patent to 
the thoughtful physician whose advice is so constantly asked. 

Exercise and massage have been used as remedial agencies 
since the days of iEsculapius, but definite instruction in their use 
has seldom been given to medical students. Perhaps a certain 
laziness which is inherent in both patient and physician tempts to 
the administration of a pill or draught to purge the system of what 
should be used in normal muscular activity, but there is a wide 
dearth of knowledge among the profession of the scope and 
application of exercise in pathologic conditions, and the neces- 
sity of care in the choice and accuracy of the dosage will be 
emphasized throughout the second part of this book. 

I have endeavered to acknowledge in the text the sources 
from which facts arc culled, but I must especially acknowledge 
my indebtedness to the inspiring friendship of my colleague, 
Dudley A. Sargent, to E. M. Hartwell, from whose classic re- 
ports to the U. S. Bureau of Education, much of the historical 
data relating to gymnastic systems was obtained; also to 
Fred. E. Leonard, of Oberlin, whose historical researches on 
physical education have been mined with rich results. The 
studies of Luther Halsey Gulick, on the development of plays 
among children, and G. Stanley Hall's work on Adolescence 
have been most serviceable sources of inspiration, while the chap- 
ters on exercise for the blind, deaf, and mental defectives have 
been founded on the work of Edward Allen, Grace Green, 



PREFACE TO THE FIRST EDITION II 

and Maurice Barr, in their respective specialties. In the section 
on medical treatment I have striven to credit other workers in 
the field with the contributions they have made, but much of it 
is my own experience, gathered from a special practice in the 
application of exercise. 

I trust that this book may help to place before the profession 
this Cinderella of the therapeutic family in her true character. 

R. T. M. 

Philadelphia, Pa. 



CONTENTS 



PART I 

EXERCISE IN EDUCATION 

CHAPTER I 

PAGE 

The Definition and Classification of Exercises. . .'. 17 

CHAPTER II 

The Behavior of the Muscles and the Lungs During Exercise . . 30 

CHAPTER III 

The Estimation of Heart Efficiency 39 

CHAPTER IV 
The Effects of Exercise on the Heart 50 

CHAPTER V 

The Control of Movement, Nutrition, and Eruption During Exercise 63 

CHAPTER VI 
Age, Sex, and Occupation „ 73 

CHAPTER VII 
The German System of Physical Training 95 

CHAPTER VIII 

The Swedish System of Gymnastics 108 

13 



14 CONTENTS 

CHAPTER IX 

PAGE 

The War of the Systems in France 127 

The Search for Harmony and Rhythm 127 

CHAPTER X 

Physical Education by Athletics 143 

CHAPTER XI 

Physical Education in Young Men's Christian Association, Camps, Boy 

Scouts, and Camp-fire Girls 164 

CHAPTER XII 

Municipal Playgrounds and Baths 184 

CHAPTER XIII 

Physical Education in Schools 214 

CHAPTER XIV 

Physical Education in Colleges and Universities 240 

CHAPTER XV 

Physical Education in Girls' Schools and Women's Colleges 270 

CHAPTER XVI 

The Physical Education of the Blind and the Deaf Mute 286 

CHAPTER XVII 

Physical Education of Mental and Moral Defectives 302 



PART II 
EXERCISE IN MEDICINE 

CHAPTER XVIII 

The Application of Exercise to Pathologic Conditions 320 

CHAPTER XIX 

Massage and Vibration • • 337 



CONTENTS 15 

CHAPTER XX 

PAGE 

Mechanical Means for Massage and Exercise 352 

CHAPTER XXI 

Flat-foot and Club-foot — Their Treatment by Exercise 371 



CHAPTER XXII 

The Cause and Treatment of Round Back, Stooped, and Uneven 

Shoulders 389 



CHAPTER XXIII 

Scoliosis — Its Causes, Varieties, Diagnosis, and 'Prognosis 416 

CHAPTER XXIV 

The Treatment of Scoliosis 435 

CHAPTER XXV 

The Treatment of Abdominal Weakness and Hernia by Exercise .... 459 

CHAPTER XXVI 

Treatment of Visceroptosis and Constipation, and Disorders of the 

Digestion, by Massage and Exercise 471 

CHAPTER XXVII 

Treatment of Respiratory Diseases by Exercise and Forced Res- 
piration 479 

CHAPTER XXVIII 

Exercise in Treatment of Diseases of the Circulation 493 

CHAPTER XXIX 

Obesity: Its Causes a^to Treatment 520 

CHAPTER XXX 

Exercise in the Treatment of Nerve Pain and Exhaustion 531 



i 



l6 CONTENTS 

CHAPTER XXXI 

TAGE 

Tic, Stammering, and Chorea , 539 

CHAPTER XXXII 

Infantile Paralysis from Anterior Poliomyelitis 546 

CHAPTER XXXIII 

Treatment of Locomotor Ataxia by Exercise 553 

Index 567 



EXERCISE IN EDUCATION AND MEDICINE 



PART 1 

EXERCISE IN EDUCATION 



CHAPTER I 



THE DEFINITION AND CLASSIFICATION OF 
EXERCISES 

The term "exercise" as here employed comprises all move- 
ments, voluntary or passive, including manipulations by the 
hand of an operator or by a machine, designed to act on the 
muscles, the blood-vessels, the nervous system, the skin, and 
the abdominal organs. 

This wideness of definition is necessary to cover its applica- 
tion and its efficacy as a medicinal agent. 

It naturally falls into the two main divisions given by Plato 
— active and passive. 

1. Active exercise requires a definite exertion of the will- 
power, whether in its more complicated form of games and gym- 
nastics, or in simple duplicate directed movements with assist- 
ance or resistance by the hands of an operator or by a machine. 

2. Passive exercise does not require any exertion of will- 
power. The various manipulations of massage, by means of the 
hands, or by the machines of Zander and others, by which con- 
tracted ligaments or muscles are stretched and nourished, local 
nutrition improved, nerves stimulated, and the abdominal 
organs affected, are restful rather than exhausting to an over- 
wrought brain. 

2 17 



1 8 EXERCISE IN EDUCATION AND MEDICINE 

Active exercise may be subdivided into, first, those involv- 
ing a single effort of one or more muscle groups, such as Hfting a 
weight or performing a feat on the parallel bars; and, second, 
exercises of endurance^ consisting of motions rhythmically re- 
pealed without great muscular expenditure for each one, and 
depending for their effect upon continuous repetition. 

Exercises of effort may be more or less violent in character or 
compound in motion, each one starting from and ending with 
rest. They are in endless variety, from simple movements of 
,lifting and throwing to the complicated combinations on the 
parallel bars and horizontal bar. In them the element of skill 
plays a leading role, and what would be a mild exercise for the 
expert may be a severe strain to the beginner, whose inaccuracy 
means the clumsy employment of many muscles that help Httle 
in its accompHshment, the contraction of some groups actually 
retarding success. Even in the accurate performance of an 
apparently simple movement, the distribution of muscular effort 
is wide, and increases tremendously with the difficulty of the 
feat. In pushing a heavy dumb-bell to arm's length above the 
shoulder, the extensors of the elbow-joint are the ones usually 
considered, but the entire muscular system shares in the effort. 
The grasping muscles of the hand are required, also the muscles 
that raise the shoulder and rotate the scapula. These are at- 
tached to the spine and ribs, which in turn must be supported 
by the pelvis, steadied on the hips, while the balance of the 
body is preserved by the muscles of the thigh and legs. 

A single, simple effort, then, may give rise to fatigue of more 
than the muscles most obviously employed. 

Education should be directed to teaching skill in the per- 
formance of such movements — skill that tends to economize the 
amount of effort required — for it is the common experience of 
shot-putters to find that their record performance is accom- 
plished with the greatest ease, owing to the smooth, accurate 
application of group after group of muscles at the proper time, 
and the perfection of balance and speed of the body's move- 
ment. 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 



19 



Muscle strains and ruptures frequently follow a sudden con- 
traction where the movement is retarded by an untimely an- 
tagonist. 

However skilful the performer may be, the whole muscular 
system participates in any violent exercise of efort. During 
the intense concentration so necessary for success, the chest- walls 




Fig. I. — The typical face of violent effort seen in sprinting, hammer-throwing, or spurting 
in a distance race (modeled from life by the author) 

are fixed; the glottis is closed, the lung§ acting as an air cushion 
for the surrounding cage of ribs and diaphragm, all the muscles 
of the trunk are steadied, and when the effort is made there 
is an explosive discharge of nervous energy, the intensity of 
which is mirrored in the muscular rigidity of the athlete's face. 
The face of such a man will show a general converging of the 
Knes to the root of the nose, with transverse wrinkles over the 



20 



EXERCISE IN EDUCATION AND MEDICINE 



bridge. The frowning brows are drawn down and the eye is 
narrowed to a mere sht. The outer angle of the eye shows the 
"crow's feet" accompanying all violent action of the muscles that 
close it. The nose and upper lip have a snarling expression, the 
nostrils are distended, and the lower lip is drawn tightly across 
the clenched teeth, except at the angles of the mouth, where 
there are little pouches caused by the pulhng of the platysma, 
which stands out along the neck like cords. The general impres- 




■The expression of effort seen in throwing the hammer. 



sion of the face is repulsive and corresponds closely to the face 
of rage, as described by Darwin.^ The lips, however, are more 
retracted than during the purely emotional state and the clenched 
teeth are exposed, presenting the appearance of one in readiness 
for tearing or seizing the enemy. 

In his drawing of rage Sir Charles Bell- shows a face corre- 
sponding closely in many respects to this one of strain. 

^ Expression of the Emotions in Man and Animals. 
" Expression of the Emotions. 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 21 

The eyes are shut with force in all violent effort, such as 
shouting, sneezing, crying, or laughing, where the compression of 
the heart and lungs, by the muscular contraction of the chest- 
walls, drives up the blood-pressure to the point of seriously 
endangering the delicate vessels of the eye from overdistention, 
the hammer- thrower or the sprinter would shut them if he could. 
Indeed, the hammer-thrower often does close his eyes at the 
moment of greatest effort. The great skin muscle of the neck, 
the platysma, springs into action wherever violent effort is per- 
formed, as in delivering a blow, and sometimes even in testing 
the grip by the dynamometer. It is the muscle of emphasis. 

Games and feats of speed, in which many movements must 
be repeated as quickly as possible in a certain limited time, may 
well be classed as exercises of effort, since practically all the 
conditions of a single effort apply to them. 

In a loo-yard dash, occupying about ten seconds, the con- 
centration of attention is continued at its highest point through- 
out. The breath is held, and the whole muscular system is con- 
vulsed with supreme effort, while the blood-pressure rises, much 
as it does in the single effort of throwing the hammer or putting 
the shot. If, however, the rate be reduced and the runner be 
allowed twenty seconds or more to cover the loo yards, the 
nervous tension disappears; the blood-pressure is but little 
affected; there is no nervous explosion, and the face remains 
calm and smiling. 

The same exercise becomes, under these conditions, one of 
mild endurance; and the possibility of this transition in the same 
exercise from effort to endurance, or from endurance to effort, 
must be constantly borne in mind, much confusion having oc- 
curred by the careless use of these terms. 

Feats of skill, such as juggling, are composed of isolated efforts 
which may be so mild in nature and so often repeated that they 
insensibly shade off into feats of endurance, especially when skill 
and practice render them automatic. The striking of a fortissimo 
chord on the piano is an exercise of effort. The practice of one 
scale for an hour would be an exercise of endurance, but the play- 



22 



EXERCISE IN EDUCATION AND MEDICINE 



ing of the thirteenth rhapsody of Liszt combines both effort and 
endurance. 

The qualities cultivated by exercises of effort, whether of 
strength, skill, or speed, include mental concentration; the rapid 
response of the muscle to the will-power; 
the ability to learn compHcated co-ordi- 
nations and the knowledge of the easiest 
and most economic way of performing 
difficult movements. Their practice is 
followed by increase in the size of the 
muscles employed up to their physiologic 
Hmit. If carried past the Kmit of power, 
the muscles will refuse to contract, or 
may actually tear, and if habitually 
overworked they may atrophy, and be- 
come hard and fibrous, with weak, un- 
certain movements. When muscles are 
overdeveloped they become parasites on 
the \'itality, which is sapped in the 
struggle to provide for their nourishment 
(Fig. 3). Exercises of effort do not culti- 
vate constitutional vigor to the same 
extent as those of endurance. 

In exercises of endurance the range 
and variety of movement are usually 
much more Hmited. They are confined 
to a few well-known varieties, such as 
walking, running, and rowing, and 
though each movement is well within 
one's power, the total amount of mus- 
cular work is great, but as the contrac- 
tion and relaxation is comparatively 
slow, the poisonous waste matter pro- 
ducing fatigue is removed from the muscles as it accumulates. 
In exercises of efort there is no time for the scavengers to 
work, fatigue of the most active muscles setting in rapidly, 




Fig. 3. — Extreme muscular 
development without a cor- 
responding increase in heart 
and lung power. This man 
could not float in sea water 
and died prematurely. 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 23 

while in exercises of endurance they can, at least, postpone its 
onset. 

This class is, then, milder and more general in character. 
It deals with co-ordinations familiar from infancy. It is not neces- 
sary to concentrate the attention on every movement in walking, 
running, and rowing — typical exercises of endurance — in them 
the mind may be occupied with other thoughts. Breathing, 
which is a muscular action of endurance, is entirely automatic, 
but is not subject to the ordinary laws of fatigue. 

The quaUties cultivated by exercises of endurance are different 
from those required in effort. Slcill is not prominent among them. 
Concentration is replaced by the attempt to liberate the atten- 
tion, and the development of any one group of muscles is second- 
ary to the indirect effect on the circulation and respiration in 
training them to remove the fatigue products of muscular con- 
traction. 

When carried to excess, exercises of endurance are accom- 
panied by acute constitutional exhaustion, shown in breathless- 
ness, from which recovery is rapid; by fatigue of the whole 
muscular system, from which a rest of a day or two is necessary, 
and by the chronic or nerve fatigue known as "staleness" among 
trainers, from which recovery may be a matter of weeks or even 
months. 

Fatigue appears in one of these three ways. 

If the exercise be sufficiently active, the amount of waste 
material suddenly thrown into the circulation is greater than 
can be eliminated by the lungs. The breathing becomes rapid 
and shallow, the pulse quick and fluttering, and the runner feels 
a sense of constriction around the chest; his head swims and 
throbs and his face takes on the anxious expression so eloquently 
telHng of the thirst for air. 

The face of the breathless man is unmistakable. The smooth- 
ness of the forehead is broken by wrinkles spreading out over the 
inner end of the updrawn eyebrows. The general direction of 
the eyebrows is just the reverse of that seen in violent effort. 
They are drawn upward and inward by what the French call 



24 



EXERCISE IN EDUCATION AND MEDICINE 



"the muscle of pain," whose action is seen in the expression of 
grief, mental distress, anxiety, or bodily pain. The upper hds in 
breathlessness droop and half cover the eyeball, giving a look of 
great lassitude to the suffering expressed by this region. The 
nostrils are widely dilated, and the mouth gapes, with lips re- 
tracted in the mad struggle 
for air. The raised upper 
lid adds to the look of sor- 
row and pain, while the 
down-drawn mouth angle, 
the tongue closely pressed 
against the teeth, the 
sunken cheek, and the 
open mouth, all go to in- 
crease the exhausted, hag- 
gard look so characteristic 
of this state, in distinction 
to mere bodily pain or 
mental suffering. The gen- 
eral poise of the head is 
backward, the chin thrust 
forward, and the neck 
strained or convulsed. 

With the re-establish- 
ment of equilibrium be- 
tween the production of 
waste and its elimination, 
the urgency of breathless- 
ness fades and the runner 
gets what is called his 
"second wind." The look 
of distress disappears from his face. The lungs regain fresh 
power to expand, the head becomes clear, and the muscles act 
with renewed vigor and elasticity. 

He can now continue running until he feels the symptoms of 
general fatigue. 




Fig. 4. — The typical face of breathlessness as 
seen in any race above 200 yards (modeled from 
life by the author) 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 



25 



If the pace has been slow enough, the runner may escape the 
acute poisoning shown by breathlessness, but sooner or later the 




Fig. 5. — The typical expression of breathlessness is seen in the last man. 




Fig. 6. — The typical face of fatigue seen after acute breathlessness has passed ofi in 
a distance race (modeled from life by the author). 

products of tissue waste accumulate, the heart beats fast and 
weak, the nervous system is stupefied, and the muscles relax. 



26 EXERCISE IN EDUCATION AND MEDICINE 

This may, in extreme cases, end in death from overexhaustion, as 
has been reported in soldiers after long and forced marches. 

The same condition may be studied in the face of the runner 
during a long-distance race. After the urgency of breathlessness 
has passed, the expression of his face changes (Fig. 6). The eye- 
brows show a slight frown, and the eyeHds are heayy, as with 
sleep; the upper lip is still retracted from the teeth, giving a 
sHght look of pain to the cheek, otherwise relaxed and flaccid. 
The mouth is half open, the jaw drops, and the lower lip hangs 
loosely over the parted teeth. The general expression is one of 
vacancy. 




Fig. 7. — Both faces show the typical expression of fatigue. 

As fatigue becomes more profound, his effort is centered in an 
endeavor to prevent the eyes from closing, as a consequence of 
the increasing paralysis of the muscles of the upper eyelids. 
The long, doubly curved wrinkles across the forehead of this 
mask (Fig. 8), which shows advanced fatigue, or the last stage 
of exhaustion, are associated with the expression of surprise and 
astonishment in most faces, but here they illustrate the endeavor 
to raise the - drooping eyelid. The nostrils are dilated, the lips 
are drawn downward and outward, the lower part of the face 
expressing the distress of failing respiration. The head is thrown 
backward and the chin thrust forward in the endeavor to bal- 
ance the head without muscular effort. Both pose and facial 
expression are characteristic of the last effort to fight off col- 
lapse. When this last effort is exhausted, the muscles of expres- 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 27 

sion cease to act, the circulation fails, the color becomes pale, 
the lips Hvid, and the runner falls in a faint. 

The effect of this general fatigue does not usually pass away 
for a day or two. The body temperature rises several degrees, 
the patient is tired, perhaps delirious, and his night is sleepless 




Fig. 8. — ^The typical face of exhaustion seen just before collapse in a distance race 
(modeled from life by the author). 

or disturbed by troubled dreams. The urine passed is of high 
specific gravity and contains albumin, casts, and blood. The 
soreness and stiffness of the muscles and joints remain for several 
days, and gradually fade away as the constitution recovers its 
tone. 



28 EXERCISE IN EDUCATION AND MEDICINE 

This may be said to represent the second form of general 
fatigue — the subacute. The third or chronic form is found in 
men during a course of training in which the amount of endurance 
required daily is more than can be regained during the periods 
of rest. The exhaustion that finally comes on is slower, but more 
profound in its effects and more difficult to counteract than 
either the acute form, corrected by a few minutes' rest, or the 
subacute form, which recovers in a couple of days. In this 
condition the temperature becomes subnormal, the weight goes 
down, the skin looks pale and flabby, the muscles lose their 
elasticity, the eye becomes dull and listless, interest in exercise 
ceases, every effort becomes a burden, and the patient sits 
■without ambition or the power to rouse himself from his lethargy. 
His sleep is broken and his appetite capricious ; his blood-pressure 
is low and his pulse increases rapidly on slight exertion. 

Recovery from chronic fatigue, or overtraining, is a matter of 
weeks, and since the nervous system is profoundly affected, a 
change of air, surroundings, and occupation, with complete 
muscular rest, may be necessary. 

It is a well-founded rule among trainers to give long-distance 
runners a rest three or four days before a race to recover com- 
pletely from the fatigue of the last practice run. 

Long-distance running has been taken as the t3^ical exer- 
cise of endurance, but just as we found that an exercise of effort 
might become one of endurance, so long-distance running may 
vary sufficiently in its pace to make it an exercise in which effort 
plays a more important part than endurance. In a mile race 
the runner will carefully regulate his pace so that the waste 
matter of muscular contraction can be ehminated almost as 
quickly as it is produced, and his resources husbanded for the 
moment when experience teaches him he can exert all his latent 
power in the final spurt. This is so timed that the finish line will 
find him completely breathless and exhausted. 

A mile race is, then, an exercise of endurance throughout 
most of the distance, and at the finish an exercise of effort, the 
change showing by the expression of the face. It is in finding 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 29 

out the pace and the point at which effort must begin that the 
genius of the true athlete is seen or the skill of the trainer is 
shown. 

Exercises of endurance, then, have much more profound in- 
fluence on the general system than exercises of effort. 

In the typical exercises of effort, such as feats of strength or 
skill, the resulting fatigue is principally a local one, and includes 
soreness of the muscles most strongly in action, which refuse 
to function when the effort becomes too great. 

In exercises of endurance the constitutional fatigue is greater, 
and powerfully affects the heart, lungs, general muscular and 
nervous systems. 

Passive exercise finds its widest field of usefulness in conditions 
of fatigue, where the elimination of waste matter must be as- 




Fig. g. — The finish of a race, showing efiort on the right, exhaustion in the center, and 

collapse on the left. 

sisted, and where nutrition of the part is impaired or destroyed. 
The patient remains inert and is acted upon by the operator or 
his mechanical substitute. Muscles can be improved in size, 
tone, and nutrition by this means, ligaments stretched and 
strengthened, the general circulation quickened, and overloaded 
veins made to disgorge their blood. The digestive tract can be 
stimulated to more active habits, and overwrought nerves 
soothed and relieved of their hypersensibility. 

These effects being more medical in character, a detailed- 
account of massage and manipulation will be reserved for chap- 
ters in Part II of this book. 



CHAPTER II 

THE BEHAVIOR OF THE MUSCLES AND THE 

LUNGS DURING EXERCISE 
«ii 

Movements of the body affect profoundly the voluntary 
muscles, the vessels which supply them with nourishment in 
the form of blood and lymph, the apparatus of respiration, the 
storehouses of nutrition in the abdomen, and the brain and 
nerves which control and direct them. 

The impetus to contract a muscle begins at the motor center 
in the brain or the spinal cord, and is carried to it by a motor 
nerve. Each muscle-cell shortens and thickens, scattering some 
of its used-up contents into the lymph-space encircling it and 
absorbing new nourishment from its surrounding plasma. By 
repeated contractions the cells thus increase both in size and 
number. The perimysium is strengthened, the fibrous walls 
surrounding the bundle of cells are toughened, and fresh power 
is imparted to the sheath enclosing the entire muscle. The 
result is an increase in bulk, strength, and elasticity. 

The normal tone of a healthy muscle keeps it in slight con- 
traction, even when at rest, so that antagonistic groups retain 
the inactive limb in normal position. The arm of the performer 
on the horizontal bar hangs at rest with elbow bent and lingers 
curved from the constant action of the flexors of the arm and 
hand, and when paralysis wipes out completely the action of a 
group, this normal tension of the opposing muscles slowly con- 
tracts and deforms the limb. 

Muscular action may be accompanied by actual rupture of 

the cell walls and exudation of blood and lymph, especially in 

exercises involving single and complete contractions. This is 

one of the two causes of muscle soreness found after severe strain- 

30 



BEHAVIOR OF MUSCLES AND LUNGS DURING EXERCISE 3 1 

ing exercise, and when due to this cause the soreness persists 
until the tear is healed and the pressure on the nerve-endings 
caused by the swollen fibers lessened. Occasionally, the entire 
muscle may be torn from its attachment to bone or tendon 
during violent exercise. 

In the slang of the trainer, these injuries are known as 
"charley horse," and the lumps which can sometimes be felt, or 
even seen, take a month to disappear, leaving a scar in the 
muscle which frequently impairs its full elasticity. 

In riders the adductors of the thigh are frequently so affected. 
Runners are always in dread of "pulling" the hamstrings at the 
junction of muscle and tendon, while the deltoid and other 
scapular muscles must be carefully prepared for action in ball- 
players to prevent this accident. 

A cold, inactive limb is endangered by any severe athletic 
test without preliminary massage or light exercise, and the lack 
of this precaution in cold weather is the cause of most rup- 
tured muscles and tendon strains. Galen recognized this fact 
in the second century and writes quaintly: 

"If anyone immediately after undressing proceed to the more 
violent movements before he has softened the whole body and 
thinned the excretions and opened the pores, he incurs the 
danger of breaking or spraining some of the solid parts, but if 
beforehand you gradually warm and soften the solids and thin 
the fluids and expand the pores, the person exercising will run no 
danger of breaking any part." 

The other cause of muscle soreness is the presence of irritat- 
ing waste matter imperfectly carried off by the blood-stream. 
This may be accompanied by the fever and malaise described 
under subacute fatigue, when the large muscle groups of the 
thighs and back are involved.^ 

Elimination is hastened by massage and made easier if the 
muscle be kept warm artificially, but as muscular action gener- 
ates heat, this usually regulates itself. 

1 Theodore Hough, "Ergographic Studies of Muscle Soreness," American 
Journal of Physiology, vol. vii, p. i. 



32 EXERCISE IX EDUCATION AXD MEDICIXE 

When one raises a light weight, it is not jerked or flung up- 
ward unless we expect to hnd it much heavier than it is. It 
is Hfted easily and smoothly at the first attempt, because we 
unconsciously adapt the means to the end. The shortening of 
a muscle does not involve the simultaneous contraction of all 
its fibers/ for single muscles are really compound, and the 
number of fibers in contraction vary according to the intensity 
of the action and to the skill and condition of the performer. 
When an individual improves his condition by exercise he merely 
increases the number of muscle-fibers which he can put into 
service. He obtains control over more and more fibers. The un- 
trained muscle has many idle strands that would lie in curves 
among the shortened and thickened members, and a muscle 
which appears to be fatigued might thus be one in which those 
fibers most accessible to the end-plates of the motor ner^'e are 
exhausted, while there may still be large areas which have not 
been within the range of stimulation. This would account for 
the enormous and otherwise inexplicable strength developed 
under delirium and in cataleptic conditions. Neuromuscular 
education by exercises of eft'ort can thus bring the athlete more 
closeh' up to his maximum of contractibility, and in conse- 
quence makes him a more efficient machine, in addition to in- 
creasing the size and number of the muscle-cells. 

As the intensity of a simple movement increases, group after 
group of unassociated muscles contract in sympathy.- The grip 
dynamometer tests the flexors of the hand and forearm, but 
in the strife for additional force muscular contraction spreads 
through the arm and shoulder, the entire muscular s}-stem be- 
comes rigid, muscles that can have no influence whatever upon 
the accomplishment of the task contract and may impede the de- 
sired movement, the intensity of which is expressed by the face. 

The cultivation of skill and promptness shortens the latent 
period between impulse and contraction and economizes this 
waste of muscular eft'ort. Not only does muscular power vary 

' Kic-th Lucas, Journal of Phj'siology, vols, xxxiii and xxxvaii. 
^ Fernand Lagrange, Physiology of Exercise. 



x> 



BEHAVIOR OF MUSCLES AND LUNGS DURING EXERCISE 33 

with the intensity of the stimulus, but Storey has shown a normal 
rise and fall of muscular power each day, high tide being regis- 
tered about eleven in the forenoon and again in the late after- 
noon. ^ 



In exercises of endurance the single movements are com- 
paratively mild. There is less tendency to shortening and 
stiffening of the muscles, and development is general rather than 
local. The long-distance runner is not noted for the thickness 
of his calves. 

Prolonged and severe exertion leads to progressive enlarge- 
ment of the heart by increasing the size and number of its 
muscle-fibers. During habitual exercise a new equilibrium is 
thus established, and the heart is able to accomplish without 
too great effort tasks with Vv^hich it could not have coped in its 
untrained state.^ The general nutrition of the heart is im- 
proved by this increased rhythmic contraction and relaxation, 
while every muscle is a throbbing heart, squeezing its vessels 
empty while in motion and relaxing to allow them to fill up.^ 

Skill does not play an im^portant part in such habitual or 
automatic movements of endurance as walking or running, so 
that their value in its promotion is comparatively sHght, though 
their value in nutrition is great. Passive exercise improves the 
nourishment of the muscle-cell artificially by alternately forcing 
out the products of fatigue under pressure, and thus keeping it 
bathed in a renewed stream of arterial blood sufficient to prevent 
wasting where active movements are impossible. 

Alternate contraction and relaxation accelerate the inter- 
change of products between blood and muscle, and vessels remain 
substantially enlarged in an active muscle even after contrac- 
tion has ceased (Fig. lo) as measured by Mosso's plethysmograph. 
Not only is this true, but the actual oxygen-carrying power of 
the blood is augmented by this heightened activity. 

1 Thomas A. Storey, "Daily Variations in the Power of Muscular Contrac- 
tion," American Journal of Physiology, vol. vii, p. 4. 
^ Rudolph Krell, Principles of Clinical Pathology. 
^ Weir Mitchell, Fat and Blood. 



34 



EXERCISE IN EDUCATION AND MEDICINE 



Philip Hawke,^ in his interesting experiments on the blood- 
count of athletes in training at the University of Pennsylvania, 
compared various forms of athletic exercise and showed an average 
of 16.8 per cent, in the number of red blood-corpuscles during 
exercise, the greatest increase being 26 per cent, in a water-polo 
player after a three-minute game. The least increase he found 
after long runs and bicycUng. Thus, if exercise be sufficiently 




Fig. 10. — A schematic diagram of Mosso's plethysmograph for the arms: a, The glass 
cylinder for the arm, with rubber sleeve and two tubulatures for filling with warm water; 
s, the spiral spring swinging the test-tube t. The spring is so calibrated that the level of 
the liquid in the test-tube above the arm remains unchanged as the tube is filled and 
emptied. The movements of the tube are recorded on a drum by the writing point p 
(Howell). 



prolonged, this increase slows down, stops, and finally decreases, 
because a large number of red cells lying inactive in various parts 
of the body are quickly brought into the circulating blood, in- 
creasing the count; a similar increase was found by John K. 
MitchelF after massage; but this reserve army, as well as the 

1 American Journal of Physiology, vol. x, No. 8. 

^ American Journal of the Medical Sciences, vol. cvii, 1894. 



BEHAVIOR OF MUSCLES AND LUNGS DURING EXERCISE 35 

original circulating number, are finally reduced by the warfare 
of muscular action. 

In active exercise a larger blood-supply is required and 
furnished, and its purification must be more thorough. The 
rate of the heart-beat and of the breathing is accelerated, the 
heart driving the blood into the arteries with a more powerful 
stroke and the lungs ehminating more of the poisons of fatigue. 
The waste consists largely of CO2, about 4 per cent, of which is 
replaced by an almost equal amount of oxygen at each breath. 
In response to stimulation of the respiratory center by the 
products of muscular action, an additional amount of CO2 can 
be eliminated by using a larger surface of lung tissue than is 
employed in ordinary life without any great increase in rate of 
breathing. Here the lung cells act somewhat in the same way 
as do the muscle-cells under training. Increased power of 
elimination can be acquired by movements of artificial or forced 
respiration which strengthen the accessory breathing muscles 
of the chest and stretch the thoracic cavity. Where respiration 
is suspended the passive and artificial movements used in 
resuscitation may bring it back. Alternate pressure on and 
relaxation of the lower ribs after Schaffer's method can main- 
tain the exchange of air in the lungs indefinitely, and by rapid 
and forced deep breathing an excess of oxygen can be stored in 
the lungs for a short time. This washing out of the lungs by 
deep breathing undoubtedly produces a temporary change in the 
constitution of the blood. It also produces a mental stimula- 
tion and definitely postpones the approach of muscular fatigue. 
If pure oxygen be inhaled the effect is markedly increased, as 
shown by Leonard Hill in his remarkable experiments on ath- 
letes. It is, however, only with great respiratory need that the 
absorption of oxygen takes place, and it will not be absorbed 
unless the conditions arise to produce increased tissue waste. 

Muscular training, especially exercises of endurance, im- 
proves the quality of the muscles so that they produce less waste, 
and it also increases the capacity of the heart and lungs to take 
care of the increased demand. If the amount of muscular work 



36 EXERCISE IN EDUCATION AND MEDICINE 

be increased beyond the rate of elimination, acute general fatigue 
or breathlessness is inevitable even if the man be in the best 
possible condition. 

During breathlessness the left ventricle gives short abortive 
beats, the blood collects in the veins of the neck and abdomen 
and also in the right heart. Breathing becomes rapid and 
shallow, and the pulse fluttering and thready. The athlete 
suffers from a form of respiratory madness, with singing in the 
ears, dizziness, a sense of impending suffocation, mental anxiety, 
confusion, and even unconsciousness. His facial expression has 
alread)'- been described (see Fig. 4) . This period of physical distress 
is preceded by one of stimulation, in which the eye is bright, the 
skin flushed, and the power of the heart-beat increased. This 
increased tension of the arterial system is also reflected by the 
improved irritability of the muscle itself (Fig. 11), noticed during 
competition in athletes before breathlessness becomes acute. ^ 

The phenomenon known as "second wind," by which the 
runner experiences a sudden relief from the agony of breathless- 
ness, is a readjustment of elimination to the increased produc- 
tion of waste. The movements of the chest and abdominal walls 
are amplified. The diaphragm makes increasing excursions for 
each breath. Ventilation by the lungs is improved. The heart 
dilates, steadies, and adapts itself to the increased task, and 
equiUbrium of waste and elimination is established on a higher 
plane. The mile runner usually gets this relief during the third 
quarter of his race, or about three minutes after the start. 

In short and intense efort, such as a sprint race, breathing, 
if any, is thoracic in character. 

The heart-beat sends a small volume of well-aerated blood 
through the central nervous system and the coronary arteries. 
The blood-pressure is high and the peripheral arteries are con- 
tracted, and the effects of non-aeration of the blood does not at 
once appear. 

In long-distance races the oxygenation of the blood and the 
demands of exertion keep pace. The breathing becomes ab- 

^ Thomas A. Storey, American Journal of Physiology, vol. ix, 1903. 



BEHAVIOR OF MUSCLES AND LUNGS DURING EXERCISE 37 

dominal. The peripheral arteries fill and the heart beats more 
fully. The respiration and the heart do better team work, and 
fatigue is not due so much to oxygen hunger as to gradual 
fatigue of the cardiac muscle. Deep breathing or inhalations of 
oxygen will give great relief to the man who runs himself out 
in a quarter- or half-mile race, but in Hill's experiments on Wolf, 
during his attempt to swim the English Channel, where his 
respiration was obstructed by the choppy sea which interfered 
with his breathing, inhalations of oxygen gave him temporary 
relief only. 

In a twenty-four-hour walk of 100 to 126 miles by the Black 
Heath Harriers, oxygen showed no restorative effect. A runner 




Fig. 1 1 . — Record of fatigue of companion gastrocnemius muscles of the frog — one normal, 
the other under the influence of carbon dioxid. The longer, or, in the later contractions, 
the lower curves, are those of the poisoned muscle. Every fiftieth contraction is recorded 
(Frederick S. Lee). 

who can hold his breath under ordinary circumstances for 
about 120 yards, after breathing oxygen for a few minutes, can 
hold it while running 220 or 300 yards, thus giving him the 
mechanical advantage of a fixed thorax for a longer time, and 
enabling him to stand a higher CO. tension without discomfort. 
It can thus make exertion easier, although the effect rapidly 
passes off.^ 

It takes the lungs about twenty seconds to respond to exer- 

1 Leonard Hill and Martin Flack, "Influence of Oxygen Inhalations on Muscu- 
lar Work," Journal of Physiology, vol. xl, 5. 



38 EXERCISE IN EDUCATION AND MEDICINE 

cise by increased respiration. This may be put as their latent 
period, and the maximum is reached in about two minutes.^ 

The effect of CO. has been graphically shown by Lee in liis 
work on the action of fatigue products on muscular contraction. 
In Fig. II the preliminary stimulation of the poison already 
referred to is seen in the higher curve of contraction found m his 
poisoned muscle at the lower part of the diagram. This period 
soon gives place to the slow and lowered line shown in the upper 
part of the diagram. 

^ G. O. Higley and W. P. Bowen, "Changes in Excretion of CO., Resulting from 
Bicycling," ^American Journal of Physiology, vol. xii, No. 4. 



CHAPTER III 

THE ESTIMATION OF HEART EFFICIENCY 

The normal pulse-rate ranges from 50 to 90 beats to the min- 
ute, with an average of 78.9 standing, 70.5 sitting, and 66.6 lying,^ 
while directly after exercise the pulse may jump to 180 beats to 
the minute, quickly returning to normal in the well-trained man. 

In the untrained man the rate remains high and often irreg- 
ular for some time, with a tendency to miss beats, ^ so that the 
examination of the pulse before and after a measured amount 
of exercise affords a ready means of testing the efficiency of the 
heart to do muscular work. 



TfT 



TTT 



■JTT 



TU- 



TC" 



15 



Ts: 



m 



"Fsn 



^ 60 
150 



a = 



40 
30 
20 
10 
100 



^i 



Fig. 12. — Chart showing averages of blood-pressure at different age periods. The 
line A-A indicates a higher than average blood-pressure in trained athletes (Barach 
and Marks). 

The increased muscular expenditure required to stand up 
increases the heart-rate 12 beats to the minute, and a variation 
of more than 20 beats in the lying and standing positions would, 
under ordinary conditions, indicate staleness. The heart-rate 
of men in athletic condition is usually 6 to 8 beats lower than 
in the same men out of condition, and the increase after exercise 
is also lessened. In 465 observations by Meylan at the begin- 

^ Ery, Encyclopedia of Anatomy and Physiology, vol. iv, 126. 
^ F. Cooke and M. S. Pembrey, "Observations on the Effects of Muscular 
Exercise on Man," British Journal of Physiology, vol. xlv. 

39 



40 



EXERCISE IN EDUCATION AND MEDICINE 



ning and end of a course of exercise^ the first test showed an aver- 
age pulse of 89 before exercise, and 135 after a strength test. 
At the end of the course the figures were 82 before and 132 after, 
although almost double the amount of foot-pounds was Hfted 
in the second test. In a football squad he found an average 
decrease of 6 beats after eight weeks' training. 



Venous R-r-t. 
150 




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Fig. 13. — Chart showing maximum and minimum pulse-pressure in the erect and 
horizontal positions in a typical case. The maximum pressure goes up in the horizontal, 
and drops in the erect, position (Barach and Marks). 

A man who suddenly springs to his feet from the lying posi- 
tion may sometimes be seen to stagger or even fall. He ex- 
periences a feeling of dizziness or faintness, which soon passes 
off, leaving him slightly flushed and ashamed of himself. There 
has been a temporary anemia of his brain because the vasomotor 
nerves which govern the contraction of the walls of the blood- 

^ George L. IMeylan, Effects of Muscular Exercise on the Heart. 



THE ESTIMATION OF HEART EFFICIENCY 



41 



vessels ha,ve been caught ''napping" and the vessels of the ab- 
domen and legs have been flooded before their walls could con- 
tract, drive the blood up to the head, and preserve the equihb- 
rium for the changed position. This readjustment to different 
postures is partly a hydrauKc problem, depending on the height 
of the column of blood to be maintained by the elastic vessel walls. 
If a man be strapped to a tilting table and the pressure re- 
quired to fill his brachial artery in the horizontal position of the 




Fig. 14. — Faught's sphygmomanometer, showing the leather cu5 in place on the arm; 
the air-pump for raising the pressure in the tube under the cuff to obliterate the pulse 
and the glass tube graduated to show the height of the column of mercuo' required; the 
surgeon's finger is on the patient's pulse. 

body measured (Fig. 13) , it will be found that the pressure is higher 
than when the body is tilted to the upright posture. The force of 
gravity has full sway and increases the pressure in the lower ex-, 
tremities at the expense of the upper. If, however, he stands up 
by muscular action and maintains himself upright, his heart does 
more work, the vessels contract in protection, and the pressure in 
the brachial artery is greater. The pressure on the arterial walls 
caused by the powerful heart action of a man in athletic condi- 



42 EXERCISE IN EDUCATION AND MEDICINE 

tion will also be greater than in others (Fig. 12), and the alertness 
and response of the vasomotor nerves to a change of posture or to 
provide for an increase in muscular work would be correspond- 
ingly marked/ lying and standing. 

The accurate measurement of arterial tension is done by a 
sphygmomanometer (Fig. 14) . The brachial artery is compressed by 
strapping round the arm a leather collar, 4 inches in width, be- 
neath which is a rubber tube, the air being pumped into it until 
the radial pulse is obliterated. The amount of pressure required 
to do this is measured by the height of a column of mercury 
forced into a graduated vertical glass tube, or on a dial in the 
aneroid form of instrument. 

Instead of palpating the artery at the wrist, a stethoscope 
may be applied just below the compressing cuff, and the sounds 
noted as they reappear during the gradual fall of the mercury 
from a point above the maximum pressure as the air is slowly 
let out of the cuff. 

The first pulse-sound heard or felt represents the systolic 
or maximum pressure exerted by the heart, and the' disappear- 
ance of the pulse-sound, the diastolic or minimum pressure.^ 

The systolic pressure rartges from no to 130 mm. in the 
young normal adult. Sir Lauder Brunton's observations, taken 
in the sitting posture, give 120 as normal for a young adult and 
from 115 to 140 for men in middle life, and for the following ages: 

Eight to fourteen years 90 mm. 

Fifteen to twenty years 100 to 1 20 mm. 

Twenty-one to sixty-five years 120 " 150 " 

Above sixty-five years, if arteries are rigid. 150 " 200 " 

In women lo" 15 " lower. 

In athletes , 15 mm, higher. 

An easy rule is to add 10 mm. for each 10 years, starting with 120 for the 
age of twenty. 

A test for athletic condition based upon the relation of the 

1 Barach and Marks, "Effects of Change of Posture Without Active Muscular 
Exertion on Arterial and Venous Pressures," Archives of Internal Medicine, 
vol. ii, 1913. 

" Goodman and Howell, American Journalof Medical Sciences, September, 
1911, and George William Norris, "Modern Instruments of Precision in the Study 
of Cardiovascular Disease," International Clinics, vol. iv, 63. 



THE ESTIMATION OF HEART EFFICIENCY 43 

pulse-rate and the blood-pressure has been designed by C. Ward 
Crampton.^ In this he notes the rise or fall of the blood-pressure 
on assuming the erect posture, varying from plus 10 to minus 10, 
also the rate of increase in the heart-beat, on the assumption that 
the heart comes to the rescue of a falling pressure by beating faster, 
its rate increasing with the necessity. Weakened tone in the heart 
and vessel walls would thus be indicated by increased pulse-rate or 
falling blood-pressure, or both, but only by taking both into 
consideration may we arrive at a correct estimation of the 
weakness. In the scale, the "loo" marks a perfectly efficient 
working of the circulation and the figure "o" approximately the 
point where the erect posture cannot be maintained. 

PERCENTAGE SCALE, BLOOD-PRESSURE, VASOMOTOR TONE 

(Crampton) 

Blood-pressure 

Pulse-rate. Increase: 10 8 6 4 2 o Decrease: 2 4 6 8 10 

0-4 100 95 90 8s 80 75 70 65 60 55 50 

S-8 95 90 85 80 75 70 65 70 55 5° 45 

9-12 90 85 80 75 70 65 60 55 50 45 40 

13-16 85 80 75 70 65 60 55 50 45 40 35 

17-20 80 75 70 65 60 55 50 45 40 35 30 

21-24 ••• 75 70 65 60 55 50 45 40 35 30 25 

25-28 :...... 70 65 60 55 50 45 40 35 30 25 20 

29-32 65 60 55 50 45 40 35 30 25 20' 15 

33-36 ; 60 55 50 45 40 35 30 25 20 15 10 

37-40 55 50 45 40 35 30 25 20 15 10 5 

41-44-. •• 50 45 40 35 30 25 20 15 10 5 o 

In case of increase in pressure higher than plus 10, add 5 per cent, to the "10" 
column for each 2 mm. in excess of 10. 

The sphygmomanometer is adjusted over the brachial artery, 
and the patient is placed on a comfortable couch and the pulse 
counted by quarter-minutes until two successive quarter-minutes 
are the same. This is multiplied by four and recorded. The 
systolic pressure is then taken, preferably by auscultation. The 
patient then stands, the pulse-rate is again counted as before, 
and the blood-pressure is again taken. The differences are 

^Medical News, September, 16, 1905. 



44 EXERCISE IN EDUCATION AND MEDICINE 

calculated and reference is made to the scale. For example, 
Case 24, aged seventeen years: 

Pulse-rate Blood-pressure 

Horizontal 68 100 

Vertical 104 94 

Difference plus 35 minus 6 

Percentage record 20 

This is a very poor record, taken from an apparently normal 
strong young football player of exceptional ability who had 
previously given records above 80. He looked quite as fit as 
usual. He was absent next day and remained home for a week 
ill with a cold and fever. It is evident that the test revealed a 
weakened vasomotor tone, the beginning of acute illness, before 
any other symptom could be noted. ^ 

A series of observations on athletes in training was taken at 
Springfield College, Mass., and embodied in a thesis by Alfred 
Weyman (1913). He found the normal blood-pressure higher 
in the standing position at the beginning of training, but in the 
course of training it changed, and by the end of the season it had 
become higher in the recumbent position. The pulse-rate was 
always higher in the standing position and after exercise. Test- 
ing this group of men by Crampton's test, the condition seemed 
to become poorer throughout the season, although the subjects 
expressed themselves as feeling well and their athletic records 
steadily improved. Improvement in skill more than counter- 
balanced condition. 

I have also seen a mile runner, undoubtedly stale and run 
down by all other tests, show a percentage of 75 under this test. 

This test must be strictly limited to an estimation of the 
vasomotor tone only; it is liable to grave fallacies owing to the 
nervous condition of the subjects, and further investigation is 
necessary to determine its range and reliability. 

A more reliable test is obtained by observing the rapidity 
with which the normal pulse-rate is restored after such an exer- 
cise as high knee stationary running.^ 

' C. Ward Crampton. 

'Wilfred L. Foster, "Physical Efficiency," P. E. Rev., vol. xix, 9. 



THE ESTIMATION OF HEART EFFICIENCY 



45 




Fig. 15. — Heart outline of a normal non- 
athletic man of sedentary habits (Shumacker 
and Middleton) . 



Severe muscular exertion increases the weight and capacity 
of the heart just as it increases the weight of the general muscu- 
lature, and hypertrophy and dilatation of the heart always result 
from prolonged muscular ex- 
ertion. This is accompanied 
by a slowing of the heart- 
beat and a higher pressure 
in the arteries as has already 
been shown. 

The heart dilates as a 
matter of economy whenever 
its work is increased. This 
economy results, first, from 
the fact that any muscle 
works at an advantage 
when somewhat elongated, 

and, secondly, because the volume of the spheric mass changes 
faster than its surface.^ 

From this it is clear that as the organ dilates the volume of 
blood pumped out by each contraction increases faster than the 

stretching of its walls, whose 
inherent elasticity also tends 
to preserve their integrity. 
It is only when the dilata- 
tion becomes excessive that 
harm may result. Such a 
dilatation of the heart is 
really an overstrain from 
which recovery is usually 
rapid in the young and 
healthy individual. 

Sir Clifford Allbutt, in 
writing of his observations 
on Cambridge students, says: "The dilatation is, I think, con- 
cerned in second wind. The healthy heart increases its output, the 

^ Roye and Adami. 




Fig. 16. — Outline from an athlete active in 
football and basket-ball for seven years (Shu- 
macker and Middleton) . 



K^ 



46 



EXERCISE IN EDUCATION AND MEDICINE 



lungs expand, resistance falls, the right ventricle pulls itself to- 
gether, and second wind is established. This process, trying 
enough to an unsound or defective heart or to elderly men, is per- 
haps never injurious to the healthy heart in young adults. I have 
many times seen undergraduates and others look ghastly at the end 
of a long spurt of exercises, but never saw a sound young man the 
worse for temporary distress of this kind. If, as in a few cases 
that I have seen again and again in growing youths, dilatation 
of; the heart occurs leading to cyanosis, the attending confu- 
sion or vertigo is generally suffi- 
cient of itself to stop the exer- 
cise in time." 

One case of acute dilatation 
reported by Stengel occurred in 
a young man sound and in con- 
dition who had been repeatedly 
examined. In the course of a 
very trying foot-ball game, both 
physically and mentally, he col- 
lapsed suddenly. When seen, he 
was bleeding at the nose, cyan- 
osed with weak fluttering pulse, 
both sides of the heart enlarged 
I inch each way. He was com- 
pletely prostrated and hysteric 
and did not gain control of 
himself for several hours. He then became rapidly better, 
and in a few days seemed quite well. After ten days' rest he 
resumed practice and regular play without any apparent evil 
after-consequences. He has engaged in athletics more or less 
actively ever since, and is now, fifteen years afterward, in excel- 
lent health. This is the most severe case of which I have any 
personal knowledge, although frequently a dilatation lasting one or 
two days is found, relieved by rest, without apparent after-effects. 
After the most severe strain one can seldom find any measur- 
able injury in a week's time in a heart originally sound if the 




Fig. 17. — Fluoroscope study by John 
W. Boyer and George W. Grier of heart 
before, after, and one week after a mara- 
thon race. An average case. Solid line, 
before; dotted line, after; dashes, one 
week after. 



THE ESTIMATION OF HEART EFFICIENCY 47 

athlete has not passed thirty (Fig. 17). It is in those unprepared 
for violent exercise, and especially when approaching middle life, 
that the danger of heart strain is most imminent. An ex-football 
player out of condition suddenly tries to repeat the exploits of 
his former days sometimes with alarming results. One, a physi- 
cian, after such an attempt, writes as follows: 

''As we finished, I became conscious of a sensation of ex- 
treme vertigo, in addition to the breathlessness which I had 
hitherto tried to disregard, and sat down just in time it seemed 
to prevent falling. The chest appeared full to the bursting-point, 
breathing entirely inadequate, and respiration very rapid. I 
remember feeling my pulse at the onset of the vertigo, and find- 
ing it almost indistinguishable. The heart-beats soon became 
strong and almost painful in their intensity, but breathing re- 
mained difficult for perhaps one-half hour. I sat still for that 
length of time before I felt equal to walking to the dressing-room, 
and even then my legs were weak and unsteady. I had marked 
nausea, but did not vomit. There was a little bloody tinge to the 
scanty sputum, and several people remarked my pallor. I 
was uncomfortable and shaky all that evening, but after a 
night's rest I felt as well as ever and have continued so." 

This is, undoubtedly, an acute dilatation of a heart on which 
strain has been put in the unfounded expectation that the 
resiliency of twenty will be found fifteen years later. 

Sometimes an elderly man fresh from his office goes moun- 
tain climbing, and at the end of a hard climb he finds himself 
in such distress as just described, a distress which does not 
disappear when he rests. His heart is found badly dilated, and 
recovery is slow if it ever takes place. Only too often the dila- 
tation remains or recurs on the slightest exertion, and he remains 
a partial or complete invalid for the rest of his life. Cases are on 
record of rupture of valves in men of forty, but I have found no 
record of such a case in the young. 

Shumacker and Middleton^ report 3 cases of acute dilatation 

^ Shumacker and Middleton, "Cardiac Effects of Immoderate College Ath- 
letics," with bibliography, Amer. Med. Assoc. Jour., 1914, vol. Ixii, pp. 1136-1144. 



48 EXERCISE IN EDUCATION AND MEDICINE 

with imperfect recovery, in a squad of 200 students active in 
heavy competitive athletic rowing at Wisconsin. They conclude 
that it is possible for injury with imperfect recovery from this 
cause to take place even in the hypertrophied heart of the athlete 
in training, although a weak heart will dilate more quickly and 
remain dilated after relatively slight exertion. Frequently 
athletes whose hearts are relatively small and weak unjustly 
suffer from imputations on their courage, which should be justly 
put down to lack of horse-power (Fig. 15), The inability of a 
man whose spirit is stronger than his flesh to rise above his limi- 
tations and drive himself in an emergency is often a cause of 
chagrin to himself and his friends. 

The presence of heart murmurs after exercise without other 
symptoms is so common as to be almost habitual in the young, 
and by its misinterpretation the necessary activity of many 
young people has been harmfully curtailed. 

Observations were taken on students at the University of 
Pennsylvania by Doctor Ira Ayer and myself^ to determine 
their frequency in different postures of the body, and under 
conditions of rest and exercise' in individuals in whom no heart 
lesion was known to exist. Murmurs were found in 74 out of 
the 266 men examined, or 27.8 per cent., much more frequent in 
the recumbent position, and when audible in standing, sitting, 
and lying postures, they were accentuated when the patient lay 
down and as the pulse became slower and stronger. 

No marked difference could be found between men who had 
led an active athletic life and those whose occupation had been 
sedentary, although murmurs seemed rather to haunt those of 
inactive habits rather than the more vigorous and athletic. 
The presence of murmurs in nearly 28 per cent, of normal young 
men even on slight exertion should, however, lead to caution 
in giving an unfavorable prognosis when they are found imme- 
diately following severe strain or fatigue.^ 

The appearance and disappearance of murmurs by change 

'"Influence of Exercise on the Heart," Am. Jour. Med. Sci., vol. cxlv, No. i. 

^ "Fifty Steps of High Knee Stationary Running." 

' "Therapeutics of the Circulation," by Sir Lauder Brunton. 



THE ESTIMATION OF HEART EFFICIENCY 49 

of posture alone is significant of their unreliability to determine 
the presence of a real heart lesion when other symptoms are 
absent. 

A heart in a state of physiologic hypertrophy (see Fig. i6) 
contains a reserve of power which, while not needed under ordi- 
nary conditions, becomes of the greatest importance at times of 
prolonged severe muscular exertion. Athletic training thus be- 
comes a process of building the heart up in size, capacity, and 
efficiency for the special purpose in view. This is shown both by 
the pulse and the blood-pressure as well as in its size (see Fig. 

12). 

In a community the stronger individuals show, as might be 
expected, a higher blood-pressure. Those with the total strength 
over 541 kg. show an average blood-pressure of 124 standing, 
while the average for those under that total is only 120.5. For 
this reason the change from active or athletic habits to a com- 
paratively sedentary life should be gradual to give the heart 
and circulation time to readjust itself to the lessening work, 
and the man is foolish indeed who during youth does not learn 
sports and muscular occupations that he can carry on in the 
years that follow school and college life. 
4 



CHAPTER IV 

THE EFFECTS OF EXERCISE ON THE HEART 

Exercises of effort and speed differ materially in their 

effect on the circulation from 
those in which endurance is 
the predominant factor.^ 

In such an exercise as lift- 
ing a heavy weight, wrestHng^ 
throwing a hammer, or sprint- 
ing, the muscles of the chest 
wall that support the shoul- 
der girdle come into energetic 
contraction, pressing the ribs 
on the elastic cushion of the 
lungs until the arm muscles 
have a firm base of action. 
The teeth are clenched and 
the larynx is closed, corking 
up the air in the lungs, where 
it is still further compressed 
by the contraction of the ab- 
dominal muscles. 

The left ventricle of the 
heart empties more quickly 
and completely under pres- 
sure, but the blood in the 
right heart cannot so easily 
be forced into the compressed 
lungs, and this side of the 
heart with the great vessels 




Fig. 1 8. — Efltect on blood-pressure of a 
hundred-yard run, showing rapid return to 
normal, followed by short period of subnor- 
mal pressure. (Oswald S. Lowsley, American 
Journal of Physiology, vol. xxvii, No. 5.) 



' A. Albu, V. Beitrage zur pathologischen Physiologic des sports, f. klin. Medl., 
1913, Ixxviii, 151; Jundell and Fries, Nord. Mek. Arkl., 1911; and Jundell and 
Sjorgen, ibid., 1912. 
50 



\^ 



THE EFFECTS OF EXERCISE ON THE HEART 



51 



that enter it becomes distended, and the engorged veins of the 
neck, temples, and forehead swell up like cords, the face flushes 
and darkens to a dusky purple. 

In a back-and-leg Uft, in which the effort was maximum, the 
blood-pressure mounted to over 200 in McCurdy's experiments,^ 
but as soon as the obstruction to the return flow was removed 
the blood-pressure fell to normal and little acceleration of the 
pulse-rate remained (Fig. 19). 



The blood 


pressure 


in eleven men before, daring, and after lifting with maximum strength ; the polae rate > before and after the Uft Average 
of several observations made on each individual. 


Name. 


Age. 


Weight 
kilos. 


Weight 
lifted in 
kilos. 


Before lift. 


During 
lift 


2-3 minutes after 
lift 


No. of beats in dis- 
tal artery between 
compression and 
disappearance of 
.pulse. 


Condition of amt 


Pulse 
rate. 


Blood- 
pressure, 
mm. Hg. 


Blood- 
pressure. 


Pulse 


Blood- 
pressure. 


Sic 


31 


70 


216 


69 


109 


210 


74 


113 


1-4 


Moderate size, muscular. 


Ma. 


2J 


61 


118 


93 


109 


165 


94 


107 


14 


Small, not muscular. 


De. 


30 


60 


131 


75 


93 


146 


76 


95 


1 


Small, not muscular. 


Sa. 


31 


68 


188 


67 


100 


175 


67 


101 


1-2 


Large, muscular. 


McC. 


33 


7S 


170 


78 


124 


178 


81 


125 


1-2 


Moderate size, muscular. 


Ar. 


21 


75 


178 


77 


117 


207 


80 


117 


1-3 


Large, muscular. 


St. 


41 


83 


149 


78 


122 


202 


77 


114 


1-3 


Large, muscular. 


Hi 


25 


60 


155 


84 


100 


154 


80 


107 


1-2 


Small, not muscular. 


Be. 


26 


61 


133 


77 


103 


157 


78 


108 


1 


■ Moderate size, muscular. 


Me. 


27 


72 


249 


76 


107 


188 


78 


110 


1-4 


Large, muscular. 


}^ 


26 


75 


152 


73 


12J 


197 


74 


130 


1-2 


Moderate size, muscular. 



^ The pulse rat.e was recorded in the recumbent as well as the standing posit 
Ihe standing position. The glottis was closed during each lift 



It seemed necessary to give het^ only the figures for 



Fig. 19. — Summary of experiments made by J- H. McCurdy. 

Lowsley showed this tendency in a 100-yard dash (Fig. 18). 
In a 220-yard race Harley Stamp showed the following 
figures in Joe Guyon, an Indian athlete in good condition: 

Systolic. 

Before 120 

After 165 

Fifteen minutes after 135 

Thirty minutes after 130 

Forty-five minutes after 120 



Diastolic. 


Pulse. 


Blood 


-pressure. 


80 


84 




40 


SO 


168 




"S 


75 


108 




60 


80 


84 




50 


80 


84 




40 



As the distance increases the subnormal pressure following 
the exercise becomes more marked and more prolonged (Fig. 20) . 

1 American Journal of Physiology, March, 1901. 



52 



EXERCISE IN EDUCATION AND MEDICINE 



We find, then, the greatest strain on the heart and blood- 
vessels in exercises of strength and speed, more especially in 
feats where the arms lift or pull great weights or support the 
body-weight, such movements involving fixation of the chest 
walls and interference with, or arrest of, the respiration. 

All exercises requiring sudden and great muscular effort 
should be used with increased caution, therefore, in those whose 




Fig. 20. — Effect on blood-pressure and pulse-rate on two athletes, C and D , 

of a twenty mile run. Note the long subnormal stage and the slow return to normal 
shown in all the curves. Ordinates = mm. Hg. pressure and rate per minute. Abscissa 
= time in minutes. (Oswald S. Lowsley, American Journal of Physiology, vol. xxvii, No. 5.) 



arteries have lost the first resiliency of youth, for in them 
damage may easily occur, as explained in Chapter III, although 
in youth no voluntary eft'ort can be violent enough to burst a 
healthy vessel. Such exercises are a test of their quality rather 
than a means of systematically developing them, and no system 
of physical education composed exclusively of such exercises 
can lay just claim to completeness. 

It is to exercises of endurance that we must look for the 



THE EFFECTS OF EXERCISE ON THE HEART 



53 



systematic development of strength and resistance in the heart 
and arteries. In mild rhythmic movements the blood-pressure 
rises gradually and never attains a great height. It remains 
high after the exercise is finished, but drops to subnormal much 
more quickly than the pulse-rate. The pulse-rate rises abruptly, 
remains high, and drops slowly at the end of the exercise. 
During this period the circulation is carried on with increased 
force and rapidity, but without great overstrain.^ 



Pulse Rate 
144 



Blood 133 
Pressure 

230 126 

220 120 

210 114 

200 lOS 

I90 102 

ISO 96 

170 90 

160 84 

X50 78 

140 72 

130 66 

120 60 

HO 54 







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Minutes-*-* 



15 20 25 30 35 40 46 50 55 60 



Fig. 21. — Curves of blood-pressure and pulse during bicycling and for thirty minutes 
afterward. Note that the puise-rate (broken line) descends only part way on the cessa- 
tion of work, and does not become subnormal as does the blood-pressure. 

Most exercises of endurance distribute the activity widely 
among the great fleshy groups of the thighs and legs, gradually 
approaching the maximum without interfering markedly with 
the respiratory movements. They do not require supreme 
efforts, and they never accelerate the activity of the heart and 
lungs suddenly or to the same extent as do typical exercises of 
effort. The aggregate of work done is very much greater, how- 

1 W. P. Bowen, "Changes in Heart-rate, Blood-pressure, and Duration of 
Systole, Resulting from Bicycling," American Journal of Physiology, vol. xi, i. 



54 EXERCISE IN EDUCATION AND MEDICINE 

ever, than in exercises of strength, except in such exercises as 
require small muscle groups only. 

Tom Burroughs could swing 3-pound Indian clubs twelve 
hours a day for six days with but little effect upon the heart 
and pulse. C. A. Gordon^ found no enlargement of his heart. 
The pulse remained at 84, and the daily rise in blood-pressure, 
was only from four to five points every evening. The muscle 
groups used were not large enough to profoundly influence it. 

Many rhythmic movements give a definite automatic mas- 
sage to the large vessels by the action of the limbs as well as the 
muscles. E version and extension of the thigh stretches the 
deep fascia and presses on the crural vein underlying it. If the 
thigh be turned inward and flexed, the fascia relaxes, drawing 
the vein wall connected with it upward and thus mechanically 
enlarging it. If the thigh be now completely flexed and inverted, 
pressure is again exerted on the vein. The rhythmic repetition 
of these motions of the thigh pumps the blood toward the 
heart, the valves of the veins allowing it to flow inward only. 
This process is continually at work in such movements as climb- 
ing, rowing, sliding, skating, and swimming, all exercises of 
endurance. 

Occupations that involve long hours of standing allow the 
law of gravitation to have full force without this self -massage of 
muscular action, and the veins of the legs become distended 
and varicose from the constant pressure of the column of blood 
they contain, and if a walk be listless enough there may not be 
enough muscular contraction to counteract this pernicious in- 
fluence, and the walker comes in tired and exhausted instead of 
buoyant and refreshed. 

Exercise should also be regulated with great care in relation 
to the age of the patient. The volume of the heart in children 
is proportionally smaller to the diameter of the arteries than 
it is later on. During adolescence the volume of the heart is 
increased twelvefold, while the diameter of the arteries increases 
only threefold.^ The child's growth is in relation to and de- 

^ Edinburgh Medical Journal, July, 1907. " Benke. 



THE EFFECTS OF EXERCISE ON THE HEART 



DO 



pendent upon this rapid development of the heart and its power 
to produce increased pressure of blood in the arteries. This 
ability increases with age, but there is always the danger of 
overfatigue in young and growing children. 

Riviere^ carefully examined the hearts of 40 boys, well built 
and sound, for a school-holiday excursion lasting one week, 
their ages ranging from seven to fourteen years. Expeditions of 
5 to 7 miles were taken daily and included a 400-foot cHmb. 
On two days the walking for the bigger boys was increased to 
12 miles. In addition to excursions, any available time was 
given over to football and games. In short, the boys were sub- 
jected to considerable physical strain, while the eight hours of 
sleep proved decidedly insufficient. Five days after their return, 
20 out of ^^ showed cardiac enlargement of various grades. This 
was to be expected, but at the end of two, four, six, and ten weeks 
only a few of the hearts each time had returned to normal, and 
10 of them, nearly all among the younger boys, stiU remained 
appreciably dilated two and one-half months after the excursion. 
It is clear that the normal limit of endurance in these boys was 
surpassed, and that the heart would require one or two years 
to recover again its normal relationship to the needs of the 
circulation. 

Leo Zuntz^ reports on a somewhat similar excursion by 32, ex- 
cursionists, all physicians, from thirty-five to sixty, who made 
the ascent of the Brocken, a heavy snow-storm considerably 
increasing the labor of their ascent. The fourth decade of life 
was represented by 8 men, who, for the most part, had had 
insufficient sleep during the previous days and had indulged 
more freely in alcohol than usual. In spite of this, 6 of them 
regarded the ascent as easy, and even the 2 others, who found 
the exertion severe, observed no bad after-effects, although one 
shortly before reaching the top had a fainting spell. The 16 men 
in the fifties made still more favorable reports, probably because 
they had taken better care of themselves in their previous days. 
Only 2 considered the ascent difficult, while the majority noted 
^ C. Riviere, British Med. Jour., Sept., 1909. ^ Zeitschrift fur Balneologie. 



56 EXERCISE IN EDUCATION AND MEDICINE 

an increase of vigor after the march. Five of the participants were 
in the sLxties, and those accompHshed the ascent best who had 
been tramed for it by g}annastic and Alpine exercise. Zuntz 
himseh", the oldest of the mountain cHmbers, being sixty-five, 
suffered a Hght febrile attack after the undertaking, because he 
had to take a rapid journey to Berlin in liis wet clothing. 

Here endurance was well maintained by those whose circu- 
lation was well estabHshed by age and experience, even with 
poor preparation for the test. Such a spell of exercise would have 
dilated and injured the hearts of boys of eight, just as there would 
have been risk of serious overstrain in the older men if they had 
attempted to force the pace beyond the rate at which their heart 
and respiration could take care of the increased stream of waste 
matter from the unusual muscular action. 

The immediate and remote eft'ects of competitive athletics 
on the heart has always been the subject of much discussion, and 
recent investigation has done much to clear up the mist of con- 
jecture and prejudiced opinion with which tliis whole subject 
has been befogged. 

The heart has been observed under severe exercise both in 
the laboratory and in actual athletic competition.^ Selig found 
the temporary disturbances following severe exertion replaced 
by normal conditions five minutes after a wresthng match in 
2 2 professional wrestlers at Prague." The apex resumed its normal 
place and the area of dulness became normal, as did the blood- 
pressure, respiration, and pulse. The short rests with which 
the wresthng matches were mterrupted were sufficient to main- 
tain equihbrium of circulation. In no case did he find a patho- 
logic dilatation of the heart. 

Doctor Captaine and IMiss Pokrychkina conclude that in a 
normal indi\ddual it is nervous strain that produces the acute 
cardiac pain, tendency to faint, and irregular pulse in the runner 
rather than the muscular work itself. 

^ "Importance of Daily Physiologic Control During Training for Athletics," 
P. Torgersen, Norsk Magazin for Laege\adenskaben , Christiania, April, 1914. 
" La Semaine Medicale, February 27, 1907. 



THE EFFECTS OF EXERCISE ON THE HEART 57 

Theodor Schott investigated wrestling as an exercise in 
which endurance is combined with repeated maximum muscular 
strains. He noted dilatation of the heart both right and left 
of I to 2 cm. or more, but also noted that all symptoms gradu- 
ally disappear in a healthy man, and that the severest exercise, 
even if accompanied by compression of the abdomen by means 
of a belt, had but a- temporary effect. All S3miptoms of heart 
insufiiciency disappear in a few minutes, and the dilatation 
tends to disappear readily and naturally, the time required de- 
pending on the elasticity of the tissues. Lehrbecher's^ observa- 
tions on oarsmen are, in the main, confirmatory. 

By far the most thorough and painstaking investigation 
of the effects of prolonged violent exercise on the heart was 
that directed by Watson L. Savage, the subjects being 59 com- 
petitors in a Marathon race of about 25 miles at Pittsburg, which 
was run in circles that brought the competitors four times during 
the race past the tents in which the physicians were stationed. 
The ages of the men were from eighteen to fifty- two years, aver- 
aging twenty-one, and they averaged about 3I pounds below the 
normal weight for their height. During their preliminary 
training they lost on an average about 6| pounds, although one 
6-footer had lost 23 pounds. The thorough and complete ex- 
amination of the pulse, blood-pressure, and heart outhne by the 
x-ray threw much interesting light on the subject. 

The hearts were divided into Jour classes, as shown in the 
illustrations (Figs. 22-25). Of 6 men with small hearts, none 
finished; of 8 with medium hearts, 4 finished; of 7 with large 
hearts, 4 finished; of 2 with very large hearts, both finished. 
One week after the race 11 men were re-examined. Of these, 2 
still showed a heart of the same size as immediately after the 
race, one a man of fifty-two years, which agrees with the previous 
statement as to the danger of men of advancing years engaging 
in violent exercise. The remaining 9 had hearts smaller than 
they were before the race, showing that the temporary enlarge- 

^ A. Lehrbecher, "Beobachtungen beine Ruder-training," Arch. f. Hyg., 1913, 
Ixxxi, I. 



58 



EXERCISE IN EDUCATION AND MEDICINE 



ment to provide for additional work ceases as soon as the extra 
necessity is relieved. 

The tracings taken in the illustration (Fig. 17) show the 




Fig. 22. — Small vertical heart; one of 
six, none of whom finished the race. 




Fig. 24. — ^Large horizontal heart; one of 
six, of whom five finished. 




Fig. 23. — Medium-sized heart; one of 
eight, of whom four finished the race. 




— Very large heart; one of two, 
both of whom finished. 



Figs. 22-25. — John W. Boyce and George W. Grier's observations by .r-ray on twenty- 
three Marathon runners. ("Physiological and Pathological Efltects of Severe E.xertion,'' 
Watson L. Savage, P. E. Review, vols, xv and xvi.) 

variations in the size of the heart before, after, and one week 
after the race. 

In these cases the physiologic changes were observed, which, 



THE EFFECTS OF EXERCISE ON THE HEART 59 

in some cases, become pathologic, and it was clearly demon- 
strated that the average individual who has trained for such a 
contest will show a pulse moderately slower than the normal. 
His blood-pressure will be higher than the average. He will 
have a compensating hypertrophy, and in many cases heart 
murmurs will be present. As soon as the race is over a recession 
into the normal follows, in some cases quickly, in others slowly, 
while in a few not at all. 

No more prolonged and exhausting test of endurance could 
be devised than such a race, and yet in former Marathon races 
Blake and Larabee found no permanent injury resulting from 
the three races they observed. 

A single cardiac overstrain with acute dilatation has no 
immediate after-effects, further than those already described, on 
the healthy young adult, but the remote after-effects of strenuous 
exercise has also been the subject of much controversy, and a 
brief review of the facts at our disposal will be of value. 

Dr. Harlow Brooks^ makes the following statement: 

"During one year I examined in this organization (a National 
Guard regiment) 12 different men, all at one time famous foot- 
ball players at college, and 6 of them ex-captains of their teams. 
Of these 12 famous athletes but i could be rated physically 
up to the average of his comrades of his own age. This one ex- 
ception, a Yale man, has since died, in his early thirties, of 
diabetes mellitus. The defects, as I have observed them, are 
chiefly confined to lesions or disturbances of the heart and other 
circulatory organs, to adiposity, and joint diseases." 

The first careful investigation to determine the after-effects 
of athletic competition was on university oarsmen at Oxford 
and Cambridge. The crew man is required to row repeatedly a 
distance of 4 miles at top speed, the twenty-five minutes being 
spent in a posture which impedes full freedom of the lungs and 
heart action. 

E. H. Morgan^ took the contestants of the interuniversity 

^American Practitioner, November, 19 12. 
^ University Oars. 



6o EXERCISE IN EDUCATION AND MEDICINE 

boat races between Oxford and Cambridge from 1829 to 1869 
as his field, and communicated directly with 151 of the 255 sur- 
vivors, as well as the relatives of the 39 who were dead, making 
a total of 294 reports received. Of these, 7 either speak of them- 
selves as probably injured or were so described by their relatives, 
sometimes with considerable reservation. On tabulating the crews- 
with reference to expectation of life, as compared with Farr^s 
English Life Insurance Tables, which place the expectation of a 
man of twenty at forty years, he found that the expectation of 
these oarsmen was forty-two years. Of the 39 deaths, he found 
II died of fever, 7 of consumption, 2 of other forms of chest dis- 
ease, 6 of accident, 3 of heart disease, i of Bright's disease, and 
8 of various causes not connected with athletics. Of the 7 deaths 
from consumption, it was found that nearly all had a strong per- 
sonal or family history. This was about the average mortality 
from diseases of the circulatory apparatus, as well as from con- 
sumption, as disclosed by the registrar-general's report, and it 
must be remembered that they rowed without prehminary 
medical examination, the unfit being weeded out by the more 
costly elimination of the oar. There were no sudden deaths nor 
rapidly fatal heart cases. 

In America, similar but much more complete observations 
were made on Harvard oarsmen by George L. Meylan of Co- 
lumbia, ^ who interviewed every survivor personally where pos- 
sible or had reports made out by their medical attendants. He 
found that 152 men had rowed from 1852 to 1892, of whom 123 
still survived (November, 1902), thus allowing eleven years to 
elapse after the last race observed to give time for any evil 
effects to show. He interviewed 76 men personally, and sent to 
all a questionnaire that was most admirable in its completeness. 
In longevity, the first crew (1852) showed an increase of 1.6 
years per man as compared with the selected lives of the insur- 
ance tables in which a man of twenty has an expectation of 42.2 
years. His results were interfered with by a number of deaths 
of men in their prime during the Civil War. By allowing to 

^ P. E. Review, June, 1904. 



THE EFFECTS OF EXERCISE ON THE HEART 6 1 

those killed in battle the ordinary expectation of men of their 
age, the advantage would be increased to 5.39 years per man. 
Of the 32 deceased oarsmen, 2 died of heart disease, i of con- 
sumption, 2 of Bright's disease, 8 were killed in the Civil War 
and by accident, 3 died of pneumonia, 2 of apoplexy, i of dissi- 
pation, I of paresis, i of cancer, and 10 of unknown causes. 
In neither of the 2 cases of heart disease was rowing given as 
the cause. The after-health was most satisfactory in 68, good 
in 36, and poor in i. Two believed that rowing had injured 
them, I claiming to have dyspepsia and the other an enlarged 
heart, which, however, had caused him no inconvenience since 
he left college. These results would seem to prove conclusviely 
that rowing is not a serious factor in the production of early 
death from disorders of the circulation, but it must be remem- 
bered that these were lives doubly selected, first for constitutional 
vigor, and secondly for muscular strength. 

Dr. WilHam G. Anderson^ found that the graduates of Yale 
who had won their "Y" on athletic teams showed a mortality 
considerably less than that of the general graduate class. 

Armstrong, of WelUngton College, in 198 cross-country and 
steeplechase runners found, of the 13 deaths from 1870 to 1904, 
that none died from heart disease. Hammet,^ in his exhaustive 
compilation of distance runners, found similar results. 

Ex-Surgeon General Stokes believes that the prolonged course 
of training required for athletic competition is dangerous in its 
effect upon those who indulge in it sufiiciently to excel therein. 
The statistics he quoted are discussed in a symposium on the 
subject.^ The rate of mortality and disability among the 625 
athletic midshipmen is, however, less than that based among the 
750 non-athletic midshipmen living under similar conditions, so 
that all available evidence would indicate that there is but 
little reason for alarm, except in cases where the test is flagrantly 

1 Yale Alumni Weekly, January 2, 1907. 

" Chas. E. Hammet, "Middle and Distance Running," Pop. Sci. Monthly, 
July, 1910. 

^ Medical Times, New York, March, 1912. 



62 EXERCISE IN EDUCATION AND MEDICINE 

unfitted to the age and condition of the competitor, or when 
the training is notoriously overdone or neglected. 

In the danger scale suggested by Dr. Bartsch^ for different 
sports, the "Gefahrenskala," whereby one could determine the 
relative likelihood of damage or injury to be encountered in row- 
ing, running, or football, would have a real value. 

Athletic competition is conducted with such intensity in 
many American schools, academies, and colleges that there is 
always danger of overexhaustion by undertaking contests that 
should be reserved for maturer years, and repeated overstraining 
of the immature heart must be injurious to its structure and 
function, its marvellous recuperative power alone preventing 
Such effects from showing more clearly than they do. 

Rubner, the physiologist, and Kraus,^ the clinician of Berlin,^ 
in a report to the Prussian Government condemn in no uncertain 
terms the whole competitive idea in sport, forbidding races of | 
mile to I mile among school boys. While one is disposed to agree 
with such a prohibition for young boys, a general condemnation 
will always be considered far too radical a step for peoples in 
which competition has always been, and always will be, an 
important factor in their systems of physical education. 

There are also dangers that accompany the later years of 
a man's athletic life. Having accustomed himself to a high 
rate of physical activity, it is dangerous to stop all exercise sud- 
denly as so many college graduates do when they enter business. 
The combination of overnourishment and undereKmination 
that is sure to follow upsets the digestion, brings on palpitation, 
and helps in the rapid accumulation of fat, and these symptoms- 
often make him introspective, morbid, and neurotic, and I have 
no doubt that some at least of the conditions noted by Doctor 
Brooks were due to this cause. 

^ H. Bartsch, "Sports und Unfall — Eine Hygienisch-chirurgische Frage," 
Berlin. Klin. Wochenschr., January 19, 19 14. 

" M. Rubner and F. Kraus: Gutachten der Koniglichten wissenschaftlichen 
Deputation fiir das Medizinalwesen vom February 11, 1914, betreffend sport- 
liche Uebungen von Schiilern, Vrtljschr. f. gerechtl. Med., 1914, xlviii, 304. 



CHAPTER V 

THE CONTROL OF MOVEMENT, NUTRITION, AND 
EXCRETION DURING EXERCISE 

The muscles are the slaves of the nerve-centers and the will 
tires long before the contractile power of the muscle is lost 
through fatigue. 

If the motor nerve to an apparently fatigued muscle be cut, 
the failing contractions can be at once strengthened by the 
electric current. Sudden anger frequently acts as a stimulus, 
making possible exertion which would otherwise be beyond one's 
power, while the muscular power displayed during the cataleptic 
state cannot be otherwise explained. 

Fundamental movements, such as breathing, eating, speaking, 
and walking, become automatic early in development, and the 
management of them is turned over to lower centers in the hind 
brain and spinal cord, so that the motor area of the highly de- 
veloped cortex may be free to supervise those more lately ac- 
quired co-ordinations that never become automatic and need 
long training to become habitual, such as piano-playing, juggling, 
or balancing. 

The acquirement of skill is, then, a training of the nervous 
system rather than of actual muscular power if it be permissible 
to speak of them separately. The mental process involved in 
solving a problem in geometry is very much the same as the 
process of thinking out a complicated attack in fencing. Fencing, 
however, cultivates the additional co-ordination of the hand, arm, 
and body to carry out the process of reasoning by which the 
fencer calculates the movement, time, and distance necessary to 
touch the plastron of his opponent without interference. 

The simplest movement means not only a nerve impulse to 
the acting muscle, but a wave of impulses to the accessory and 

63 



64 EXERCISE IN EDUCATION AND MEDICINE 

antagonistic groups which act as brakes to steady the movement. 
If the movement is unfamiliar, this combination of forces is not 
very well adjusted. Contraction is jerky and inaccurate, in- 
stead of unerring and graceful or physiologically economical. 
Many useless muscles are employed and the expense in nervous 
energy is out of proportion to the result. 

The first attempt at comparatively simple motions rapidly 
exhausts the attention. The apparently aimless and uncertain 
movements of a child learning to walk illustrate the amount 
of concentration required in what afterward becomes automatic. 
Exercises of skill cultivate habits of economy in the expenditure 
of nerve force, and we instinctively admire a difficult exercise per- 
formed with thrifty ease just as we unconsciously censure the 
nervous prodigality of the unskilful tyro. The same effect 
produced by mental excitement or worry on fine muscular ad- 
justment is seen in the broken shoe-lace of the hurried man or 
the failure of the nervous pianist before a critical audience. 
When a certain degree of skill or co-ordination is learned in a set 
of movements the interest passes on to what is more difficult, 
and this is one reason why any course in physical training should 
begin witli simple and easily learned movements, progressing to 
those more difficult and complicated feats that serve to keep 
alive the attention and interest of the pupils. 

The possibiHties of muscular development and co-ordination 
are incredible. An acrobat after unremitting labor succeeded in 
accompHshing the following feat of balance : The upper end of a 
walking-stick was arranged to fit the hand. Standing balanced on 
a slack wire, he placed on it the lower end of this stick and gradu- 
ally raised himself to a single hand balance. It is only by analyzing 
the strength of the muscles immediately involved and the fine 
judgment in muscular co-ordination required in pushing up to 
the final position with feet in the air, as well as the control and 
alert sense of equihbrium that we begin to realize a Httle what 
possibiHties exist in neuromuscular control, and yet a dissec- 
tion of the back and side of this man would not show anything 
more than a well-developed group of scapular muscles. The 



CONTROL OF MOVEMENT, NUTRITION, AND EXCRETION 65 

important element is nervous control rather than actual muscle 
size. 

New co-ordinations require constant attention, but when they 
become automatic they allow the attention to be transformed to 
refinement of the form and finish. Most pupils perform a new 
exercise correctly in a general way, but distinction of style always 
requires conscious effort, and by emphasizing such points a 
teacher can invest with renewed interest a gymnastic drill which 
has become mechanical and dull. 

Exercises should be designed to develop and educate move- 
ments peculiar to the Hmb — the lower limb for support and leap- 
ing, the upper limb for grasping, striking, throwing, and catch- 
ing.i 

In other words, the movements should be natural and 
utihtarian. It is because this great principle is so much neglected 
that the interest is difficult to maintain in formal gymnastics. 
In free play it takes care of itself. 

Exercises of strength and skill would be employed to train 
co-ordination and the economy of effort, as well as that alertness 
of mind so necessary in ordinary fife. They shorten the period 
between thought and action and give that condition known as 
presence of mind. A corresponding mental strain is inevitable. 

The man who is held alert too long on the starting fine before 
a race, tense and straining for the signal, finds such a rapid ex- 
haustion of his powers of concentration that in a second or two 
the strain becomes intolerable. The alertness required at first 
in learning to box rapidly exhausts the nervous system and it is 
only when the movements of countering, ducking, and sidestep- 
ping become habitual that the exercise can be continued for any 
length of time. Baseball is, above all, a training in quick think- 
ing and alert action. Football is a game of the same nature, 
and getting the jump on an opponent is a matter of mental con- 
centration and alertness rather than of actual strength. Much 
of the exhaustion of a game is due to this brain fag, for the actual 
playing time in a match is not more than one-fourth of the total 
1 Baron Pierre de Coubertin, La Gymnastique Utilitaire. 
S 



66 EXERCISE IN EDUCATION AND MEDICINE 

period. In gymnastic exercises imitation is a cheap form of 
instruction from the standpoint of nervous expenditure, because 
the pupU learns more easily through the eye than by translating 
a verbal command into a picture of the movement, while ex- 
ercises by command are much more exhausting to the attention 
of the pupil, although they have thus an additional educational 
or disciplinary value. The wars between the German and 
Swedish systems of gymnastics have been fought upon the rela- 
tive value of imitation and command. 

Griesbach's experiments^ show that the mental fatigue 
caused by the lesson in Swedish g3annastics was almost as 
great as that of the more purely mental exercises, a result doubt- 
less of the concentrated attention required, but without this 
possibility of fatigue the educational value might not be so great. 
Exercises of endurance, which are simple, habitual, or even 
automatic, do not require great nervous concentration. A man 
can walk or run slowly and have his mind on other things, but 
when he pushes his powers to the point of acute fatigue the 
phenomena of breathlessness already described takes place. If 
the exercise be continued after breathlessness has disappeared 
the runner soon begins to notice a sensation of lassitude creep- 
ing over him, an increasing lethargy and paralysis of the will- 
power. His muscles become slower and slower in their response 
to his will, each effort requiring a greater concentration of his 
attention. This lassitude gradually deepens. Group after group 
of muscles refuse to perform their work, until he staggers along 
with relaxed grip, yielding ankle, fallen jaw, and drooping 
eyelids, drunk with the poisons of fatigue. 

Repeated attacks of fatigue produce that chronic poisoning 
referred to in Chapter I as stateness or overtraining, which is, 
above all, a slow poisoning of the nervous system, just as sub- 
acute fatigue is a general intoxication by the products of muscle 
waste and acute fatigue, an intoxication of the breathing appa- 
ratus. 

^ Energetik u. Hygiene des Nerven Systems in der Schule, Munich and Leipsig, 
1895, p. 97; International Magazine of School Hygiene, 1905, vol. i, 317-417. 



CONTROL or MOVEMENT, NUTRITION, AND EXCRETION 67 

During stateness the life of the athlete has but little ambition. 
Supper is enjoyed the least of the three meals. The vitaUty decHnes 
as the day progresses. He is unable to concentrate on study or work 
and takes but little interest in the world about him. He awakens 
tired after sleeping and his sleep is frequently broken. He finds 
it difficult to hold his attention on any subject. The physician 
notes that the eye is sunk deep in its socket, the face is pinched, 
the appearance dejected, the temper peevish and distrustful, 
aggravated by little things. Wounds and scratches heal slowly. 
Sudden rise to the standing position shows an increase in the 
pulse-rate of 20 beats or more. Blood-pressure is low and falls 
markedly when the man stands up, although to this rule I have 
seen some notable exceptions in men who were evidently over- 
trained. There is a gradual loss of weight from day to day, and 
the weight lost during exercise is not replaced within twenty-four 
hours as it should be. Rest and feeding alone can bring the for- 
mer elasticity, although much can be done by the mechanical 
nourishment of the muscles by massage. 

The role of passive exercise is one of relief to the nervous sys- 
tem, for the nutrition of muscles is maintained without the 
expenditure of the nervous force required to make them con- 
tract, and massage acts on the central system through the nerves 
of sense, stimulating or soothing according to the nature and 
amount of the manipulation. 

The burning up of carbohydrates and proteins by muscular 
action causes a hunger for food just as the destruction of oxygen 
produces a. hunger for air. With an increased supply of food 
the muscles increase in size and strength, and the amount re- 
maining Unused is either excreted or stored up in the tissues as 
fat. If training be severe, not only is the daily supply of food and 
drink used, but the normal reserve horde of fat is speedily ex- 
pended until a man in fine athletic condition is considerably 
below his normal. 

Athletic training aims to produce a machine to run, leap, 
fight, or row, and fat would only be an incumbrance like extra 
ballast, so that a man in fine athletic form is not in the best 



68 EXERCISE IN EDUCATION AND MEDICINE 

condition to rise from a depleting illness or to resist the siege of 
an exhausting infection like typhoid fever or pneumonia, where 
the stored-up fat of the normal individual becomes his most 
valuable asset. 

The immediate loss of weight, mostly water, during athletic 
exercise, may be from 5 to 8 pounds in less than one-half hour; 
a loss which continues more slowly after exercise is stopped if no 
food or drink is taken. In a series of observations made by Wm. 
J. Cromie on football players during daily practice at the Uni- 
versity of Pennsylvania he found that the loss averaged about 3 
pounds, the highest being 5yV pounds and the lowest, y% pound, 
the weight being taken immediately before and after exercise. 
During the next hour they showed a further loss of about | 
pound, and in no case was any gain found. 

In the foot-ball squad of the Springfield College every 
man gained in weight during one playing season, the average 
being 8yV pounds. There was in most cases a loss of weight 
at first, and then a slow gain, attributable to the increased 
muscular development which more than counterbalanced the 
initial loss of fat. Almost without exception the -men gained their 
daily loss before going to bed. One man lost 6| pounds in an 
afternoon and regained it that night.^ 

Trainers rely on changes in weight more than any single 
indication of an athlete's condition, always looking with well- 
grounded suspicion on the man whose weight keeps going down 
from day to day.^ 

A high state of continued muscular activity uses up the 
nitrogen suppHed by the proteins of the food and stored for 
emergencies like the fat already alluded to. Edward Pay son 
Weston, the pedestrian, during a six-day walk consumed much 
more nitrogen than was taken in from his food; in other words, 
he lived on the combustion of his own tissues. During the rest 
period which followed, the balance was quickly restored.^ Blythe, 

^ F. J. Gray, "Diurnal Variations in Weight," P. E. Rev., 1910, and T. A. 
Storey, "Loss of Weight During Exercise," P. E. Rev., vol. vi, 2q. 

^ E. H. Nicholls, Boston Medical and Surgical Journal, January, 1907. 
^ Austin Flint, Proceedings of Royal Society, 1884. 



CONTROL OF MOVEMENT, NUTRITION, AND EXCRETION 69 

Atwater, and Sherman have since confirmed the observation that 
athletes draw upon the body for nitrogen unless it is supplied in 
excess, although the actual loss of body weight may not be great. 

In a six-day bicycle race C. W. Miller lost 4 pounds on the 
first day and maintained his weight after that for the rest of the 
week, although he rode 2007 miles with only twenty-four hours 
rest, of which eight were spent in sleep. Frank Albert, one of his 
opponents, lost 3/0 pounds in the first two days, but got it all 
back at the end of the week under an excessively nitrogenous 
diet. This discovery led trainers to supply a highly nitrogenous 
diet consisting largely of meat and eggs.^ 

McCurdy's experiments (over ten years) on foot-ball teams 
would indicate that the amount of proteins supphed in response 
to this discovery has been excessive, and that the strain on the 
excretory function of the bowels and kidneys has been made 
too great in consequence. This he relieves by increasing the 
fats and curtailing the supply of milk, cheese, and meats,^ while 
Professor Irving Fisher has shown that men on a vegetarian or 
low protein diet show powers of endurance that surpass the meat 
eaters almost beyond the limits of creduHty.^ 

The first two organs to act in the ehmination of the poisons 
of muscular waste are the lungs and the skin, the former giving 
off heat, CO2, and water vapor, and the latter water, urea, and 
other constituents of minor importance. Both these organs 
also neutralize by evaporation the excessive heat produced by 
muscular action. Every hour we sit still we lose about 40 gm., 
or 1 1 ounces; this loss of weight from the skin and limgs goes on 
even during sleep, as shown by Warren P. Lombard on his del- 
icate balance (Fig. 26). 

The normal loss of weight during the night is nearly i pound. ^ 

1 W. G. Atwater and H. G. Sherman, "Effects of Prolonged and Severe Mus- 
cular Work on Food Consumption, Digestion, and Metabolism," U. S. Bull. No. 98, 
Dept. of Agriculture. 

^ Elmer Berry, "Effects of a High and Low Protein Diet on Physical Efi&ciency," 
P. E., Rev., May, 1909; and Otto Folin, "Theory of Protein Metabolism," Am. 
Journal of Physiology, February and March, 1905. 

^ Yale Medical Journal, March, 1907. 

* Thomas A. Storey, P. E. Rev., December, 1902. 



70 



EXERCISE IN EDUCATION AND MEDICINE 



The function of excretion as carried on by the kidneys is 
greatly increased by any form of exercise. The by-products of 
muscular action removed by the kidneys are water, uric acid, 
urea, oxalates, lithates, and numerous other substances. These 
show as reddish deposits, principally uric acid, in the urine, 
especially of those not habituated to fatigue. 

While albumin is present in all normal urine, it is scarcely 
detectable in a large percentage of cases until it is increased 
by changes in diet, by cold baths, exposure, mental worry, strain, 
and exercise.^ 




Fig. 26. — Curve of loss of weight of F. M. A. (aged twenty-nine, weight 72 kilos), 
5.30 p. M., May 24, 1906. Room temperature, 24.5° C; hygrometer, 55 degrees. The 
small oscillations were caused by {he respirations.- Time is marked in minutes at the 
bottom of the curve: a-b, Subject asleep; b-c, waking curve; at c, 4 grams added; d-e, 
waking curve; at e, breath held in quiet expiration; at/, a large inspiration when subject 
begins to breathe;/— g, curve shows rapid loss of weight following the holding of the breath. 
At b, he was partly asleep, eyes closed, lids twitching. He was told to open his eyes and 
did so. He was not startled and was not seen to make any other movement (Warren P. 
Lombard). 

The frequency and extent of albuminuria depends almost 
directly on the extent and severity of the exercise.^ The albu- 
min does not persist after the first urination following exercise, 
as a rule, although there are many exceptions, and the amount 
is greatly increased where, in addition to the exercise, there is the 
nervous tension of an exciting contest. 

Seventy-three per cent, of basket-ball players show an 
appreciable amount of albumin after match games, but only 

1 Edwin Wells Dwight, "The Significance of Albumin and Casts in the Urine 
of Apparently Healthy Applicants," New England Life Insurance Co. Bulletin. 

" Elmer Berry, "Athletic Albuminuria," with bibliography, P. E. Rev., 
January, 1912. 



CONTROL OF MOVEMENT, NUTRITION, AND EXCRETION 7 1 



29 per cent, after the daily practice. The amount also varies 
with the duration of the game, a thirty-five-minute game giving 
a cloud, while a seventy-minute game will give a heavy cloud. ^ 
In Savage and Barach's experiments on Marathon runners, 
blood was found in several cases after the race and albumin 
was found in every specimen from a mere trace to a heavy 
cloud, whereas in 19 specimens examined a week afterward 4 



990 

qei 
qs-o 
97. 8 



3^ 



//- 6 6 10 19. SL H- ^ 5 10 a i H- 




Fig. 27. — Curve showing the daily variation in temperature of nine normal individuals 
at complete rest. ("Some Observations Upon the Deep Temperature of the Human Body 
at Rest and After Muscular Exertion," Bardwell and Chapman, in British Medical Jour- 
nal, May 13, 1911.) 

showed light clouds. The presence of albumin is closely asso- 
ciated with a rise of temperature. After the Marathon race at 
the Olympic games of 1904, the temperature of 12 contestants 
was taken per rectum and a rise from 2 to 3.40 degrees was 
noted. This rise, also noted by Bowen, is, I believe, constant, 
although it may not show if the mouth temperature alone be 
taken. This constant fever after exercise may go as high as 104 

1 E. Fred MoUer, Thesis, 1910, Sprinfield International Y. M. C. A. College. 



72 EXERCISE IN EDUCATION AND MEDICINE 

in healthy persons, and remain up for an hour or more. The 
internal temperature in the normal healthy person has a daily 
normal fluctuation of about i^ degrees, being lowest at four and 
highest at ten o'clock, remaining up until about six o'clock in the 
afternoon (Fig. 27), the rise having definite relation to muscular 
activity.^ The rise of temperature is in direct proportion to 
the severity of the exercise: in basket-ball it went up to 2.40 
cm., handball to 1.94 cm., and after fight exercise 1.35 cm. 
Savage found that the man who finished his Marathon race in 
the best condition and said that he felt no distress had a rectal 
temperature of 104 degrees. Bard well was able to foretell the 
exact degree to which it would be raised by definite doses of 
exercise. 

This would go to prove that after severe exercise there is 
always a nephritis, lasting from a few hours or days to a week, 
according to the severity of the exertion and the condition of the 
subject. 

The sediment present after exercise resembles the sediment 
in severe nephritis, and this condition is evidently due to the high 
tension induced in the circulation by the exercise.^ 

Training can modify this nephritis by fimiting the amount of 
waste, but in our understanding the place occupied by condition- 
ing and efimination we have not advanced much even in phrase- 
ology on Hippocrates: 

"The untrained have moist flesh, and when they exert them- 
selves the body becomes heated and they yield the product of 
liquefaction in abundance. Of this, whatever is sweated or 
purged away with the breath causes no trouble except to so much 
of the body as has undergone the unusual depletion, but what- 
ever remains causes trouble not only to the unduly depleted part 
of the body, but also to whatever part receives the liquid in 
question, which is not akin to the body, but hostile." 

1 N. D. Bardwell and J. E. Chapman, British Medical Journal, and W. L. 
Caldwell, Thesis, 1912, Springfield College. 

" Christensen, "The Urine Sediment in Athletes and Nephritics," Hospital- 
stidende, Copenhagen, lii, July 21, and August, 1912. 



CHAPTER VI 



AGE, SEX, AND OCCUPATION 

The growth and development of a child is directed by the 
play instinct, an automatic system of physical education com- 
posed of spontaneous exercises of his own devising. The first 
movements of the infant consist of kickings and squirmings, 
with aimless motions of the arms, hands, and head, for almost the 
only co-ordinations that he has from birth are those of sucking 
and grasping, both intimately associated with his survival. 

Each infant should have several 
hours daily for free exercise, en- 
cumbered by Httle or no clothing. 
Place the child on a bed and 
guard him from falling off, or place 
him on the floor protected by a 
warm rug. Give him something 
to kick against, the wall or foot- 
board, and a ring or handkerchief 
to pull on with his hands. A small 
but increasing amount of time 
should be spent playing with the 
baby, pressing the hands against 
the feet to excite the pushing re- 
flex, roUing the baby over, moving 
the arms up and down, or present- 
ing a finger for the httle hands to 
grasp and clutch. Some children 
tend to he stiU for long periods, and may require to be 
played with more than those who are spontaneously active. 
Long clothes or tight clothing interfere with normal creep- 
ing and should be discarded at least during exercise. There 




Fig. 28. — An infant three weeks 
old which supported its own weight, 
suspended by its arms, for two min- 
utes (after Dr. L. Robinson). "In- 
fancy of Animals," Py croft, Henry 
Holt & Co. 



74 EXERCISE IN EDUCATION AND MEDICINE 

should be the side of a crib, a rail, or a chair to grasp in 
pulling himself up to a stand. This partial support is specially 
useful lor heavy babies, and helps to prevent the bowed legs that 
result from the efforts of too ambitious parents. He should be 
taught to climb a step 5 or 6 inches high, and should be allowed 
to fall off the step on to a thin pillow, and, so safeguarded, will 
learn about falling and will handle himself better than if he had 
never learned the self-control that can come only with oppor- 
tunity. As he progresses more compHcated movements should 
be taught, like the picking up and throwing of objects, and this 
stage of his growth culminates in learning that supreme ac- 
complishment of man, the conquest of the upright position. 
He should not be stimulated to stand too long upon his feet at 
first, and it is at this point that the pile of clean sand begins to 
assert its importance. In it he should stand and fall, dig and 
build with large and simple toys, like blocks, sticks, stones, and 
boxes. Four hours a day is not too much for free play in the 
fresh air, with the utmost possible freedom from clothing, loose 
canvas jumpers at most. 

The amount of muscular work done by an infant in the course 
of the day is quite as great as that done by an active adult, 
weight for weight, as proved by Schlossman's tables, and the 
researches of W. E. Custer, at Clark University, and any cur- 
tailment of this necessary activity must be harmful. 

This routine may continue up to the age of seven, when, in 
most cases, the responsibility of the child's day is shared by the 
school. About this age catching and all games of ball begin to 
engage the child's attention, irrespective of sex, also individual 
games, like tag, hide and seek, leap frog, and other tests in which 
the awakening powers are tried, but it is not until about twelve 
that the boy begins to find his medium of expression in com- 
petitive games, and in those that demand the sacrifice of the 
individual to the team. This evolution of the play life is graphic- 
ally shown in Dr. Luther Halsey Gulick's chart of the play of 
Anglo-Saxon boys; in other words, boys having the most highly 
developed play traditions and customs. He divides the child's 



AGE, SEX, AND OCCUPATION 



75 



life into three periods: from birth to seven, from seven to twelve, 
and from twelve to maturity. The spaces enclosed by the curved 
Hues include the games that are acquired at each stage and also 
those that are retained to a more advanced age. These lines 



Anglo-Saxon Bovs' Piays 
(Neuro-Muscular.) 



Kicking. 
Whole arm, body 
and hand movements. 
Dropping things. Blocks. 
Sand Plays, digging, piling, etc. 
Running, throwing, cutting and fold- 
ing. Swinging. 

Shooting, guns, bows, slings, etc. 
Knife work. Tools of increasing 
complexity. 



Machinery. 
Sailing. 
Rowing. 
Swimming. 



Ball 
games. 
One old cat. 
TTirowing. 
'buck on Fungo. 
a rock. 



Gymnastics. 
Indian Clubs, 
etc. 



Tag. 
Cross tag. 
Word tag. 
Prisoner's 

base. 
Ride and 

Rounders, _, , ' 
,. Black man. 

Leap frog. "'^* 

Track and Marble games. "Stunts," 
Field Sports, '^t' cints. hole, etc. 
Foot-ball games. Care of 

land and animals. ^^^" Baseball. 
Hunting, fishing. j^ Basket-ball. 
War. Wrestling, ^r Cricket. 
Boxing, fencing. /. Hockey. 

Predatory. / Gangs. 

Billiards. / Houses in woods. 

Bowling. f Pals. 

Predatory gangs. 
Hero service. 



1.UTHEH GULICK. 



Pig. 29. — Luther Gulick's table, showing the age at which various games and sports begin, 
are most popular, and wane in interest among boys. 



must not be considered final, since in many individuals the 
beginning of interest in any play may be earlier or later than the 
time stated, and in all children they begin gradually, come to a 
climax, and shade off just as gradually. As age progresses, they 
drift from plays that center in the individual to plays in which 



76 EXERCISE IN EDUCATION AND MEDICINE 

they consider themselves as related to others. Growth is accom- 
panied by an increased complexity in the movements required, 
and in the third division, beginning approximately at the age 
of twelve, the start of what is termed the "gang" instinct, is 
seen, boys conducting their sports in groups, team work being 
the keynote of this stage, as individual excellence was of the 
preceding. 

It must not be forgotten, however, that the games acquired 
in the second period also persist and often dominate the boy 
throughout his entire growth. GuUck has pointed out that 
savages who have reached the stage of co-operation required for 
fighting under a chief in organized tribes are really doing what 
the Anglo-Saxon boy does at the age of twelve. All the higher 
forms of sport involving team work and speciahzation are merely 
a physical expression of the law of evolution that governs the 
business and social Hfe of a civilized community. ^ 

In outlining a course of physical education for any child the 
first consideration must always be given to this law of physical 
evolution, and his natural plays and games must be studied and 
used educationally for his welfare. FroebeP recognized this 
fundamental law and developed it into his kindergarten. Until 
the age of twelve there is but little difference in the spontan- 
eous play of boys and girls, but with the consciousness of sex 
and the accelerated growth of puberty their interests rapidly 
diverge. Girls retain their individualism, and do not come 
under the domination of the "gang" instinct to the sam.e extent 
as boys. The fighting reflex is not so dominant. They do 
not inherit the ability to throw straight and strike hard, 
and thus are put at a disadvantage in games requiring these 
activities. Their periods of temporary disabihty make them 
take less interest in active and competitive games, and they 
have much less endurance. Their dress Hmits their stride. 
They cannot fall and roll over with propriety. This differ- 

^ Karl Groos, "Play of ]\Ian" and "Play of Animals," D. Appleton & Co. 
G. Stanley Hall, "Adolescence," D. Appleton & Co. 

" F. W. A. Froebel, "Education of Man," D. Appleton & Co. 



AGE, SEX, AND OCCUPATION 77 

ence increases as they come under the social influence of the 
community, but doubtless part of it is instinctive. Their interest 
turns to more feminine accomplishments, requiring grace and 
lightness, and much pleasure is found in swimming and dancing 
in all its forms and in games in which rhythmic movement is 
prominent. 

It is not until a comparatively mature age physically that 
the more formal gymnastics can be introduced and applied to 
correct the confinement of school, shop, or home Ufe. During 
adolescence, sports and games play so large a part in the physical 
development that a definite classification of the outstanding 
effects of the most famihar of them will be of value for guidance 
in their selection. It is impossible to give any great degree of 
exactness to such a table without cumbering it with wearisome 
explanations. In a familiar exercise like walking the change in 
speed from 3 to 5 miles an hour will elevate an automatic list- 
less occupation into a vigorous exercise, employing many new 
muscle groups and stimulating the heart, lungs, and skin, while 
the change from a smooth level road to the broken ground of a 
mountain side may be dangerous for one who might walk at 
moderate speed on level ground. 

The muscles employed are named approximately according 
to the intensity and duration of their action. The notes in the 
column marked "Demand on the Nervous System" refer to the 
concentration required, its degree varying with the difficulty of 
the movement. The "Influence on Respiration and Circulation" 
of an exercise is indicated by the onset of breathlessness and in- 
crease in blood-pressure and pulse-rate during its practice. 
The "Physical Characteristics Cultivated" by the constant 
repetition necessary for success in such games come in the 
fourth column, and the "Age Limits" within which they should 
be contained are placed in the last but one. The time of life 
for beginning and leaving off any exercise must vary greatly 
with the individual, but the ages mentioned are not far out for 
the average man. The upper age limit in all cases is placed at 
sixty. If by that time a man has not determined what form of 



78 EXERCISE IN EDUCATION AND MEDICINE 

exercise is most suitable for his condition and constitution, he 
is not likely to be capable of receiving guidance from this chart. 

There is always danger of exhaustion and overstrain from 
excessive athletic competition, but early adolescence and middle 
age are the danger periods. The heart of the boy of fifteen is in 
no condition to withstand the exhaustion of extreme tests like 
the so-called IMarathon races. Any distance-run for boys should 
be broken by rests or changes of pace, as explained in the chapter 
on athletics. About this time a lad's ambition is apt to out- 
strip his \dtaHty, and although immediate recovery is usually 
good, repeated and continued overstraining of the heart must 
always be bad. As we advance in years our heart adapts itself 
to an habitual rate, just as the range of movements in the joints 
slowly lessens and the danger of overstrain from an unusual call 
on either heart or muscle becomes greater as their adaptability 
and resistance become more and more Hmited. Preparation for 
any unusual muscular test or strain should then be made with 
added care as the years accumulate. Fortunately, Nature 
generally reduces this danger to a minimum by decreasing the 
desire and ability to drive one's self beyond the margin of discom- 
fort, and by prompting the question, "What's the use?" in face 
of a supreme test of strength, speed, or endurance. Striking 
examples are continually quoted of exceptional men who have 
long passed the "dead line" and are still active in such sports as 
cricket, baseball, and boxing. If indulgence in a sport has been 
continued mth regularity, a man's own feelings as to when it 
must be abandoned are better indications than any fixed rule. 
It is dangerous, however, for an elderly gviiinast to attempt his 
youthful feats after a long interval of idleness and disuse. How- 
ever long he may have lain fallow, he is often unwillmg to accept 
the limitations of his years. This danger was once strikingly 
illustrated to me on the person of an authority on gymnastics, 
who, in attempting a simple feat with which he had been familiar, 
strained the muscles of his neck so badly that he was incapaci- 
tated for several weeks. 



AGE, SEX, AND OCCUPATION 



79 



CLASSIFICATION OF ATHLETIC GAMES AND EXERCISES 









Influence 














on pulse, 


Physical 


Best 




Exercise. 


Chief regions of the 


Demand 


blood- 


character- 


age for 


Remarks. 


body used. 


on nerve 


pressure. 


istics culti- 


prac- 






control. 


and res- 
piration. 


vated. 


tice. 




Baseball. 


Right or left fore- 
arm, shoulder, and 
the whole muscular 
system to a lesser 
degree. 


Great. 


Moderate. 


Accuracy, 
speed, and 
agility. 


12-30. 


Amount of exercise 
depends on the posi- 
tion played; pitcher 
has his pitching arm 
constantly v e r - 
worked. 


Bowling. 


Right forearm, arm, 
shoulder, and back. 


Great. 


Slight. 


Accuracy 

and 

strength. 


14-60. 




Boxing. 


All of forearm, arms, 
shoulders, chest, 
back, and thighs. 


Extreme. 


Great. 


Alertness, 
agility, 
strength, 
courage. 


16-40. 




Cricket. 


The whole muscu- 
lar system moder- 
ately: right or left 
forearm, arm, and 
shoulders. 


Great. 


Moderate. 


Accuracy, 
speed, and 
agility. 


12-60. 


Depends on position 
played; exercise ob- 
tained by bowler is 
different from that 
of the fielder. 


Cross-coun- 


Thighs and legs. 


Slight. 


Extreme. 


Endurance, 


18-25. 


A severe test of the 


try running. 








speed, and 
strength. 




heart. 


Dancing. 


Thighs and legs. 


Extreme. 


Great. 


Endurance 

and 

agility. 


14-60. 


Clog and soft shoe 
exercise only the 
legs, but many acro- 
batic, postural, and 
esthetic dances 
bring in the trunk 
and arms. 


Fencing. 


Thighs, back, shoul- 


Extreme. 


Moderate. 


Speed, agil- 


18-S0. 


When fencing is done 




ders, and arms. 






ity, alert- 
ness. 




with alternate arms 
all tendency to one- 
sided development 
is avoided. 


Football 


Thighs and legs. 


Moderate. 


Great. 


Agility, 


12-35- 


In this game the ball 


(soccer). 








speed, and 
strength. 




is not touched by 
the hands, but is 
kicked by the feet 
and butted by the 
head only. 


Football 


The whole muscu- 


Extreme. 


Great. 


Accuracy, 


16-30. 


The most severe field 


(Rugby). 


lar system. 






endurance, 
speed, 
agility, and 




game on the heart 
and lungs. 


Golf. 


The whole muscular 
system moderately. 


Extreme. 


Slight. 


courage. 
Accuracy. 


18-60. 


The walking inter- 
rupted by the 
strokes of the game 
make it peculiarly 
valuable for those 
living a sedentary 
indoor life. 


Hammer- 


Shoulders and back. 


Extreme. 


Slight. 


Accuracy 


16-SO. 


A difficult feat of co- 


throwing. 


also arms and 
thighs to a lesser 
degree. 






and 
strength. 




ordination as now 
practised, i. e.,from 
a 7-foot circle. 


Hand-ball. 


The whole muscular 
system, particu- 
larly the back. 


Great. 


Extreme. 


Accuracy, 
speed, and 
agility. 


16-40. 




Hockey. 


The whole muscu- 
lar system, espe- 
cially the back 
and right (or left) 
forearm. 


Extreme. 


Extreme. 


Speed, agil- 
ity, accu- 
racy, and 
endurance. 


12-30. 


An extreme test on 
the heart and lungs. 



8o 



EXERCISE IN EDUCATION AND MEDICINE 



CLASSIFICATION OF ATHLETIC GAMES AND EXERCISES 









Influence 














on pulse. 


Physical 


Best 




Exercise. 


Chief regions of the 
body used. 


Demand 
on nerve 


blood- 
pressure, 


character- 
istics culti- 


age for 
prac- 


Remarks. 






control. 


and res- 
piration. 


vated. 


tice. 




Hurdling. 


The whole muscu- 
lar system, espe- 
cially the abdom- 
inals, thighs, ham- 
strings, and calves. 


Extreme. 


Great. 


Speed, agil- 
ity, and 
endurance. 


16-25. 


The high hurdles 
(3 ft. 6 in.) require 
great accuracy. 


Jumping 


Thighs, lower back. 


Extreme. 


Slight. 


Agility and 


14-25 


Jumping without a. 


(high). 


and shoulders. 






speed. 




run cultivates agil- 


Jumping 


Thighs, calve, back, 


Great. 


Slight. 


Agility and 


14-25 


ity only. 


(broad). 


and shoulders. 






speed. 






Lacrosse. 


All the muscles of 
the legs and arms. 


Great. 


Extreme. 


Speed, 
endurance, 
agility, and 
accuracy. 


12-30. 


A running game with 
frequent intervals 
for rest. 


Mountain- 


Thighs, legs, and 


Slight. 


Extreme. 


Endurance. 


16-40. 


A severe test on the 


climbing. 


back. 










heart and lungs, 
particularly in high 
altitudes. 


Pole- 


Forearm, arms. 


Extreme. 


Slight. 


Agility and 


14-25. 




vaulting. 


shoulders, abdo- 
men, thighs, and 
legs. 






strength. 






Riding 


Back, abdomen, 


Slight. 


Slight. 


Balance. 


14-60. 


The mechanical shak- 


(horseback). 


and thighs. 










ing has a distinct 
therapeutic effect. 


Polo (pony). 


Right or left arm, 
back, abdomen, 
and legs. 


Extreme. 


Great. 


Accuracy, 
balance, 
strength, 
and cour- 


16-30. 




Running, 


Whole muscular 


Extreme. 


Great. 


age. 
Speed and 


12-30. 


A typical exercise of 


ioo-2ooyds. 


system, especially 
the thighs and 
calves. 






alertness. 




effort. 


Running, 


The whole muscu- 


Great. 


Extreme. 


Speed and 


19-30. 


A severe test on the 


440-1000 


lar system except 






endurance. 




heart and lungs. 


yds. 


the arms. 












Distance 


Thighs and calves. 


Moderate. 


Extreme. 


Endurance. 


19-30. 


A severe test on the 


running (i 












heart and lungs. 


mile and 














upward). 














Rowing. 


Back, forearm, arm, 
flexors, shoulder 
muscles, andthighs. 


Slight. 


Extreme. 


Strength 
and endur- 
ance. 


16-40. 


Thighs are practi- 
cally unused, except 
with the sliding seat. 


Shooting 


The whole muscu- 


Slight. 


Moderate. 


Endurance. 


16-60. 


Value depends on 


(hunting). 


lar system, espe- 
cially the thighs, 
legs, and back. 










tramping over ir- 
regular ground and 
open air. 


Shooting 


The whole muscu- 


Extreme. 


Slight. 


Accuracy. 


18-60. 




(target). 


lar system, very 
rnoderately. Arm 
flexors and all of 
forearm. 












Shot- 


Right (or left) fore- 


Great. 


Slight. 


Strength, 


16-50. 




putting. 


arm, triceps, shoul- 
ders, back, and 
thighs. 






speed, and 
agility. 






Swimming. 


The whole muscu- 
lar system. 


Moderate. 


Great. 


Endurance 

and 

strength. 


12-60. 


Racing and diving 
are extreme tests on 
the heart and lungs. 
Swimming for dis- 
tance at a moderate 
speed is a test of 
endurance and 
stamina. 



AGE, SEX, AND OCCUPATION 



8i 









Influence 












Demand 
on nerve 
control. 


on pulse, 


Physical 


Best 




Exercise. 


Chief regions of the 
body used. 


blood- 
pressure, 


character- 
istics culti- 


age for 
prac- 


Remarks. 






and res- 


vated. 


tice. 










piration. 








Tennis. 


The whole muscu- 
lar system, espe- 
cially right (or 
left) forearm and 
arm. 


Great. 


Moderate. 


Accuracy, 
speed, agil- 
ity, and 
endurance. 


14-40. 


Tennis - elbow is 
caused by constant 
repetition of back- 
hand stroke, pro- 
ducing strain of 
pronator radii teres 
muscle. 


Walking. 


Thighs, legs, and 
back. 


Slight. 


Moderate. 


Endurance. 


16-60. 


Two to four miles 
an hour is mild ex- 
ercise. Four to six 
miles may be ex- 
hausting, if kept up 
very long or if road 
is rough. 


Water polo. 


Whole muscular 
system. 


Extreme. 


Extreme. 


Endurance, 
strength , 
agility, and 


18-25. 


An extreme test of 
the heart. 


Wrestling. 


Whole muscular 
system, especially 
neck, back, arms, 
shoulders, and ab- 
domen. 


Extreme. 


Great. 


Strength, 
endurance, 
agility, 
speed, and 
courage. 


16-40. 





From the standpoint of therapeutic effect, or even rapid 
development, most athletic games are inaccurate and wasteful 
of time. For these purposes they do not compare with the 
accurate movements of gymnastics. During a baseball game 
an outfielder may spend four-eighths of his time standing with 
his hands on his hips, another three-eighths sitting on the 
bench, and the remaining one-eighth at the bat, on the bases, 
or in the practice of throwing the ball. For an expenditure of 
two hours or more he gets nothing but fresh air and a little ex- 
ercise for his right arm and shoulder. In one hour of football 
the time occupied in actual play is about ten minutes, the rest of 
the time being spent in discussion, disentangling the team after a 
play, and in preparing for the next play, the exhaustion follow- 
ing a game being largely nervous. 

Games and gymnastic exercises especially designed for a 
specific purpose can be applied to remedy defects or weakness 
more quickly and surely than sports whose object is recreation 
alone. No game growing up in a community of children could 
teach alertness like Doctor Sargent's "curtain-ball," a game in 



82 



EXERCISE IN EDUCATION AND MEDICINE 



which two courts are separated by a curtain 8 feet high, each 
side attempting to throw a basket-ball so as to touch the floor of 
its opponent's court and at the same time defend its own from a 
similar fate. Gymnastic apparatus was originally made to imi- 
tate the tools and appliances of the outdoor world. The hori- 
zontal bar was at first the branch of a tree, the climbing pole a 
mast, and the ropes its rigging. The wooden horse of the gym- 
nasium dates from the days of chivalry, but the agile and com- 
plicated movements that give it interest and value would be 
impossible on its living prototype. Many of the exercises on 
the horse would indicate that it also represents a log on which 
to balance and from which to leap. 

In the following table the main characteristics of the more 
familiar pieces of gymnastic apparatus are classified as they 
were in athletic games: 



CLASSIFICATION OF GYMNASTIC APPARATUS, EXERCISES, AND 

GAMES 







Demand 


Influence I 


Ap- 
proxi- 
mate 

age 
limit. 




Exercises. 


Chief regions of the 
body used. 


on ner- 
vous 
control 
and co-or- 


on blood- 
pressure, 

pulse, 
and res- 


Physical 
qualities 
cultivated. 


Remarks. 






dination. 


piration. 






Basket-ball. 


The whole muscu- 
lar system, especi- 
ally legs, thighs, 
and lower trunk. 


Extreme. 


Extreme. 


Agility, ac- 
curacy, and 
endurance. 


16-30. 


An extreme test on 
the heart. 


Bom 


Flexors of fingers. 


Moderate. 


Slight. 


Strength 


16-S0. 




(Swedish). 


wrist, and forearm, 
flexors of arm. all 
of shoulder, and 
abdomen. 






and 
balance. 






Buck. 


All of forearm, arm, 
and shoulders; 
thighs and legs. 


Moderate. 


Slight. 


Agility, bal- 
ance, accu- 
racy, and 
precision. 


12-40. 


Thighs and legs ex- 
ercised principally 
during approach 
and finish of move- 
ment. 


Curtain- 


The whole muscular 


Extreme. 


Moderate. 


Alertness, 


1 2-40. 




ball. 


.system, especially 
thighs and legs. 






speed, and 
agility. 






Dodge ball. 


The whole muscular 
system, especially 
thighs and legs. 


Great. 


Moderate. 


Alertness, 
speed, and 
agility. 


1 2-40. 




Flying 


Flexors of hand. 


Great. 


Moderate. 


Strength, 


16-30. 




rings. 


wrist, forearm, 
arm, shoulders, 
and abdominals. 






rhythm, 
balance, 
and 






Horizontal 


Flexors of fingers, 


Extreme. 


Moderate. 


courage. 
Strength, 


16-30. 




bar. 


wrist, forearm, 
arm, pectorals, la- 
tissimus dorsi, and 
abdominal muscles. 






balance, 
rhythm, 
and 
courage. 







AGE, SEX, AND OCCUPATION 



83 







Demand 


Influence 




Ap-. 
proxi- 
mate 

age 
limit. 




Exercises. 


Chief regions of the 
body used. 


on ner- 
vous 
control 
and co-or- 


on blood- 
pressure, 

pulse, 
and res- 


Physical 

qualities 

cultivated. 


Remarks. 






dination. 


piration. 






Horse 


All of forearm, 


Moderate. 


Moderate. 


Agility, 


14-30. 


These exercises are 


(long). 


arm, shoulders, 
abdomen, thighs, 
and legs. 






balance, 
strength, 
and 
courage. 




vaulting and leap- 
ing, and so de- 
velop thighs and 
legs more than side 
horse. 


Horse 


All of forearm, arm. 


Extreme. 


Slight. 


Balance, 


1 2-40. 


Thighs and legs de- 


(side). 


shoulders, abdo- 
men, thighs, and 
legs. 






accuracy, 

rhythm, 

agility, 

and 

strength. 




veloped in the ap- 
proach and finish, 
but much less than 
arms and shoul- 
ders. 


Ladders. 


Flexors of fingers, 
wrist, forearm, 
arm, pectorals, and 
latissimus dorsi. 


Slight. 


Slight. 


Strength. 


14-60. 




Medicine 


All of forearm, arm. 


Slight. 


Slight. 


Strength 


14-60. 


An excellent exer- 


ball. 


shoulders, back, 
abdomen, and 
chest. 






and 
accuracy. 




cise for developing 
all muscles above 
the pelvis. 


ParaUel 


All of forearm, arm, 


Great. 


Moderate. 


Strength, 


16-30. 


Influence on co-ordi- 


bars. 


shoulders, pecto- 
rals, abdomen, and 
latissimus dorsi. 






balance, 
accuracy, 
and 
rhythm. 




nation depends 
greatly on the in- 
tricacy of the exer- 
cises practised. 


Rope- 


Fle.xors of hand and 


Slight. 


Slight. 


Strength. 


1 2-40. 




climbing. 


arm; latissimus 
dorsi. 












Spring- 


All of thighs, legs. 


Great. 


Moderate. 


Agility and 


12-30. 




boards. 


and lower back. 






accuracy. 






Tag games. 


The whole muscular 
system, especially 
legs and thighs. 


Moderate. 


Great. 


Speed and 
agility. 


12-18. 




Trapeze. 


Flexors of hand, 
wrist, forearm, and 
arm; all of shoul- 
ders, the abdom- 
inals, and latissi- 
mus dorsi. 


Extreme. 


Moderate. 


Balance, 

strength, 

accuracy, 

and 

courage. 


12-30. 


One set of exercises 
are for equilibrium 
only; another are 
like the typical hori- 
zontal bar exer- 
cises in their effect. 


Tumbling. 


The whole muscular 
system, especially 
legs, back, and 
neck. 


Extreme. 


Great. 


Rhythm, 

agility, 

strength, 

balance, 

accuracy. 

and 

courage. 


14-30. 


One of the best all- 
round exercises. 



Here again it must be borne in mind that, in addition to the 
circles on the horizontal bar, the swinging exercises on the 
flying rings, vaults on the horse, and balancing exercises on the 
parallel bars, the same exercise may be interchangeable from one 
piece to another. 

The choice of exercise will depend then not only on its known 
effects upon the heart and circulation, but also upon the stage 
of development of the nervous system. 



84 EXERCISE IN EDUCATION AND MEDICINE 

The "lower level" (Hughlings Jackson), consisting of the 
spinal cord and lower part of the brain governing the co- 
ordinations that early become reflex, is developed during the 
first years of life. The "second level," or sensory motor level, 
involving the cortex, has its great development from seven 
to twelve, and all the finer motor and sensory development 
takes place during these years. The "upper level," which 
involves judgment, control, association of ideas, is only of later 
growth. 

There is no hygienic reason why a boy of twelve should not 
play golf or fence, but, as a matter of fact, few boys will choose 
these games of themselves. They are "upper-level" games, and 
for the same reason it is the exception to find an eighteen-year- 
old boy interested in the activities of the sand pile. 

For the healthy boy or girl of eighteen or thereabouts the 
best development would be obtained by a judicious mixture of 
gymnastic and athletic exercise in the open air. A course 
should be designed so as to employ all the activities of the 
muscular system — strength, accuracy, speed, agihty, and endur- 
ance — as naturally as possible. A period of gymnastic exercise 
should begin with a ten-minute drill, including movements for 
both arms and legs, with special emphasis on correct carriage of 
the body and on deep breathing. This should be followed by 
exercises in rope-climbing, on the parallel bars, horizontal bar, 
or flying rings, in which the arms are used. Following this, 
exercises of agility like vaulting over bars or the German horse, 
and simple ground tumbflng. Each lesson should conclude with 
running or with a gymnastic running game of sufficient speed to 
test the endurance. The period should occupy one-half to 
three-quarters of an hour and should be repeated at least 
three times a week. If alternated with walks or out-of-door 
games, as described in a subsequent chapter, the maximum de- 
velopment and general education of the physical powers should 
be obtained. The mental exhilaration arising from the emula- 
tion and competition that is found in a large class is an influence 
by no means to be neglected, especially in the young, although 



AGE, SEX, AND OCCUPATION 



85 



exercise will have its effect whether this be present or not just 
as surely as iron or castor oil. 

For those of mature age and a sedentary life exercise should 
be directed principally to the muscles of the arms and trunk, 
care being taken not to overtax the circulation. Such exercises 
as throwing the medicine ball, a large ball weighing from 7 to 
12 pounds, hand-ball, and other ball games, combined with 




Fig. 30. — The use of the medicine ball for class work. 



simple apparatus work, are usually effective and interesting. 
If combined with the leg work and the fresh air obtained in a 
game like golf, tennis, or a brisk walk in the country once or 
twice a week, the result would be increased efficiency in business 
and a general feeling of well being. For those of advancing 
years the necessity for exercises becomes less urgent, and the 
individual usually develops some plan to suit his own case. 
In a lecture given at the age of eighty-three. Sir Hermann 



86 EXERCISE IN EDUCATION AND MEDICINE 

Weber spoke as follows on his method of using exercise for the 
prolongation of life: 

"I have mostly commenced," he said, "with moderately 
deep inspirations and expirations, continued duriilg three to five 
minutes once or twice a day, and have gradually increased the 
exercises to ten minutes or one-quarter of an hour. The depth" of 
each inspiration and expiration and the duration of holding the 
breath are likewise to be only gradually increased. At the be- 
ginning one-quarter of a minute for every inspiration or expira- 
tion ought to be sufhcient. If this is well borne, each act may 
gradually be prolonged in duration so that in the majority of 
cases each inspiration and each expiration may be brought up 
to a minute. All the movements are to be made slowly, not 
rapidly. I usually advise to inspire in an upright position, with 
raised arms and closed mouth, to bend down the body during 
the expiration so that the fingers touch the ground or the toes. 
By degrees one can do several up-and-down movements during 
every inspiration and bend and raise the body several times 
during the expiration. By this alternate bending and raising 
of the body we can gently strengthen the lumbar muscles, and 
through this successfully combat the tendency to lumbago. 

"Another useful combination with the respiratory exercises 
is the turning of the body around the axis of the spinal column 
alternately, with deep inspirations from left to right and with 
expirations from right to left, the arms being half raised. By 
this movement we bring into action some of the muscles of the 
spine, which are apt to be only imperfectly used by most persons 
in advanced years, and the stiffness of the neck and spine and 
the tendency to stooping so common in old persons can be to 
some degree corrected by this kind of movement. If com- 
menced in good time and practised regularly and thoroughly, 
swinging the arms around the shoulder-joint is likewise useful, 
and other combinations with muscle and joint movements will 
occur, but they should have accustomed themselves to these 
respiratory movements. The latter ought always to have our 
principal attention, since to them the beneficial effect on the 



AGE, SEX, AND OCCUPATION 87 

heart and lungs is mainly due. In addition to the influence on 
the circulation, the respiratory movements keep up the nutrition 
and efficiency of the lungs, which undergo in old age a kind of 
atrophy. The walls of the smallest divisions and air-cells become 
thinner, and a kind of senile emphysema is developed which by 
this exercise is to some degree prevented. Another important 
influence consists in maintaining the elasticity of the chest walls, 
which are apt to become stiff in old age and thus to interfere 
with free movements of the lungs and pleura. If, for some 
reason, the erect position should be inconvenient, respiratory 
movements can be made also in the horizontal and sitting 
positions." 

In addition to these exercises, taken regularly every morning, 
he strongly advises a walk lasting from one-half to three hours, 
part to be taken in the morning and part later in the day, and 
once a week he recommends a day of more prolonged exercise 
and a holiday once or twice a year spent in a walking or cHmbing 
tour of three or four weeks. 

Occupation should have equal weight with age in choosing 
exercise. 

In the natural occupations of man, like farming, fishing, 
and lumbering, a great deal of muscular exertion in the open 
air is required and the need for it is thus naturally provided for. 
During the last hundred years, however, the proportion of town 
dwellers in America has risen from 2 to nearly 60 per cent. , and 
the artificial and confining conditions of a crowded city life must 
be faced. The segregation of masses of people limits the amount 
of space and air for each, and the necessity of further economizing 
energy by the use of machinery reduces muscular activity to a 
minimum. This applies especially to the most "civilized" part 
of a civilized community, so that there has arisen a whole series 
of defects and diseases due to this suppression of natural muscular 
activity or its concentration on a few movements. 

School children are taken for five hours a day from their 
natural occupation of outdoor play and confined more or less 
strictly to a sitting or standing position, making their bodies 



55 EXERCISE IN EDUCATION AND MEDICINE 

fertile soil for the growth and development of postural defects. 
It is necessary, then, that exercise in the open air for city children 
of the school age should be obtained by playgrounds situated in 
the more congested districts. 

The construction of roof gardens, recreation piers, and other 
open-air breathing spaces is also directed by this same need, 
and the gymnastic exercises for school children described in 
detail in a subsequent chapter are designed primarily for correct- 
ing the physical deterioration inevitably associated with confined 
school Hfe. 

The difference between the physical life of a factory employe 
who tends a machine and of a man whose active life is spent on 
the farm or in a lumber camp is at once apparent, but even 
among business men the effect of underexercise and overeating is 
familiar to the physician whom he consults for his constipation, 
biliousness, and headache, while the increase in nervous disorders 
in both men and women of a highly civilized community shows 
the disastrous effects of city life on the overstimulated nervous 
system. Among the influences that help to produce these con- 
ditions are the ease of intercommunication by mail, telephone, 
and telegraph. By these means alone a man may double or 
treble the amount of business done before their use, but at an 
added nervous expenditure. The constant harrowing of the 
emotions by the press, with its daily tale of horror, is a morbid 
addition to his load. 

Those who live the confined indoor life of the office or study, 
overtaxing the brain and slighting the muscular system, will 
derive benefit from any exercise sufficiently vigorous to stimulate 
the circulation and the skin. It is to such men and women that 
correspondence schools are most ensnaring with their promises 
of incredible results from the modest expenditure of a few 
moments daily, while the secrecy with which they are shrouded 
and the high price demanded for instruction adds not. a little 
to their allurement. The exercises are never complicated or elab- 
orate. They are usually simple, definite, clearly described, and il- 
lustrated. Although there is little originality in their design, 



AGE, SEX, AND OCCUPATION 



89 



there is a novelty in the manner of their statement that appeals 
to the uninformed and partly informed with the force of a new 
truth. In a circular sent by one, the writer begins by stating 
that "all movable parts of the body have muscles to move them 
and also muscles to move them back again," so that by using 
one muscle or group to resist the action of its antagonist the 
same development can be reached as by the use of weights. 




Fig. 31. — Flexion of arms with resistance of the extensors and contraction of the thigh 

and leg muscles. 



The use of one muscle group to antagonize another is the prin- 
ciple upon which this and other systems are built. 

A typical exercise would be the simple flexion and extension 
of the arm, during which attention is concentrated on the flexors 
of the arm (Fig. 31). The fist is tightly clenched and the arm is 
slowly flexed with intense resistance from the lengthening 
triceps, so that during the movement the entire arm is in a state 



90 EXERCISE IN EDUCATION AND MEDICINE 

of tension. To increase the effect, the subject stands with knees 
everted and slightly bent and the muscles of the thighs in vigor- 
ous contraction. 

The advantage of such movements is evident to a business 
man who is not ambitious to excel in games or sports, but who 
wishes to get his necessary exercise in "tabloid" form, and it is 
to him that such a proposition makes its appeal. Great num- 
bers can be treated at their homes through written directions 
sent by mail, and ephemeral institutions are formed in the 
business sections of cities and tilled with patients by a personal 
canvass from office to office. Twenty minutes daily of this in- 
tense work, involving the large muscle groups of the legs, trunk, 
and shoulders, powerfully stimulate the heart and respiration, 
draw the blood out to the extremities, and cause profuse per- 
spiration. When followed by a shower-bath and a rub down it 
produces the same good effect both physically and psychically 
that would be derived from an equal amount of other exercise. 
Increased strength of a certain kind is sure to follow such a 
course, a strength to grip or to lift, and the drudgery of it is not 
without its good points. These exercises will quickly develop 
the muscles, and they interest for a time many who would not 
otherwise take any form of exercise. Their utility to cultivate 
the qualities most useful for the habitual muscular movements 
of every-day life and their abiUty to give all-round develop- 
ment is another matter. In this respect they do not stand the 
test well. In such a course there are no movements requiring 
fine or complicated co-ordination, and there are none that aim 
at the acquirement of skill or dexterity. For a man who wishes 
to excel in playing a game like golf, tennis, or other games re- 
quiring lithe, graceful, and accurate motion, these exercises are 
not only valueless, but detrimental. They make him muscularly 
self-conscious and break up that fine adjustment of co-ordination 
so necessary for quick, strong, unerring movements. They 
ignore the law of muscular relaxation and economy of energy 
essential to the precise and graceful accomplishment of any 
muscular act, and they overlook the importance of the free and 



AGE, SEX, AND OCCUPATION 



91 



far extension of the extremities characteristic of such actions as 
throwing, thrusting, and striking, so necessary to counteract 
the constant posture of flexion produced by sedentary occupa- 
tions. The stress put upon the circulation by this excessive con- 
traction is also great, and may overstrain a heart organically 
weak or encumbered by deposits of fat. 

The design of a short course of exercises without apparatus 
for the average business man of mature age and sound consti- 
tution has been undertaken by Dr. Luther Halsey Gulick in his 
•'Ten Minutes' Exercise for the Busy Man," and by J. P. Miiller, 
of Klampenborg, Denmark, in his "Fifteen Minutes' Work a 
Day for Health's Sake," where the first eight movements ter- 
minate in a bath and are followed by ten exercises in self-massage, 
and by WiUiam J. Cromie, in his "Fifteen Minutes Invested 
Daily for Health." 

The following list has been compiled and found of proved 
value by the author for those to whom the more mteresting and 
varied but time-consuming exercises and games are prohibited 
by circumstances. These exercises may be done in the morning 
on rising, or late in the afternoon, before 
dinner, and should occupy about fifteen min- 
utes. 

They aim to stretch the thorax and expand 
the lungs, to give the heart some vigorous work, 
and to agitate and massage the abdominal 
organs, but one should begin gradually, take 
long rests, and use few movements at first. 

Exercise i. — Position: Standing. Arms 
at sides, chin to neck, abdomen in, and chest 
carried well forward without contracting the 
shoulders. 

Movement: Arms forward raise, palms 
down, upward stretch, rise on tiptoe (Fig. 32), 
inhale. Sideward lower, palms back, keep- 
ing arms straight, slowly exhale and lower heels. Repeat 
twenty times. 




Fig. 32. 



92 



EXERCISE IN EDUCATION AND MEDICINE 



Exercise 2. ^-Position: Standing, arms behind back, hands 
resting in small of back, fingers interlocked, with palms facing 
backward (Fig. 33). 

Movements: Straighten arms, turning palms in, then down 
and then out, keeping fingers interlocked. Roll shoulders and 
arms into supination, extend neck (Fig. 34). Hold this position 
for a moment and then reverse slowly back to starting position. 

Note. — When the fingers can- 
not be kept in this position, 
start .by holding a loop of cord 
in the hands instead of inter- 
locking the fingers. Repeat twenty 
times. 






Fig. 33- 



Fig. ^4. 



Fig. 35- 



Exercise 3. — Position: Lying on back, hands on hips. 

Movements: Raise each thigh alternately with bent knee 
until it touches the abdomen. Clasp hands around leg and press 
in on abdomen (Fig. 35). Relax. Repeat twenty times. 

Exercise 4. — Position: Standing, hands behind head. 

Movements: Bend sideward to right, then forward, then to 
left (Fig. 36), and then backward, circling five times each way. 
Keep feet together and the knees straight. Get far down on 
each side. Repeat twenty times. 

Exercise 5. — Position: Standing, hands clasped behind head 
(Fig. 37)- 

Movements: Force the head and elbows back strongly, 
relax, letting the elbows come forward. Repeat twenty times. 

Exercise 6. — Feet 30 inches apart, arms at sides. 

Movements: Raise arms above head, bend forward and 
touch floor with both hands (Fig. 38). Rise slowly and bring 
hands to position. Repeat twenty times. 



AGE, SEX, AND OCCUPATION 



93 



Exercise 7. — Position: Arms forward (Fig. 39), then out and 
then up, stationary run. 





Fig. 36. 



Fig. 37- 



Movement: At the rate of fifteen steps in five seconds, take 
fifty steps for each position of the arms. 





Fig. 38. 



Fig. 39. — Stationary running. 



Fig. 40. 



Exercise 8. — Position: Standing, hands clasped across ab- 
domen. 

Movement: Inhale, pressing in abdominal wall (Fig. 40). 
Exhale, relaxing abdomen. Repeat twenty times. 



94 



EXERCISE IN EDUCATION AND MEDICINE 



Exercise 9. — Position: Sitting on stool or on side of bed, 
hands clasped behind the back. 

Movement: Trunk rolKng, forward to right; backward, and 
then to left (Fig. 41) ; then up to starting position. Repeat twenty 
times. 





Fig. 41. 



Fig. 42. 



Exercise 10. — Position: Standing. 

Movement: Arms sideward raise, upward stretch, inhale. 
Forward bend (Fig. 42), and rise. Arms sideward lower, ex- 
hale. 

To Finish. — Wring out a Turkish towel in cold water, take it 
by both ends and rub hard the back, chest, abdomen, and 
thighs. 



CHAPTER VII 

THE GERMAN SYSTEM OF PHYSICAL TRAINING 

It is to Germany that modern physical education must look 
for one of the most powerful influences in its development, and 
the somewhat acrimonious discussions that fill gymnastic litera- 
ture, between its supporters and the followers of Ling, the Swede, 
have done much to clarify the principles on which the German 
system is based. 

It is necessary here to review briefly the origin and growth 
of German gymnastics and their introduction to America. 

To Basedow belongs the honor of first combining physical 
and mental education in the general trainmg of the European 
youlE! liTTTT^rKelouiKled, at Dessau, the "Philanthropinum," 
to realize Rousseau's method of nature, "so that the training of 
the mind and body shall serve to assist each other." He em- 
ployed the knightly exercises of riding, fencing, vaulting, and 
dancing in educating the sons of the burghers. He also drew 
his exercises from popular German sports, rowing, swimming,^ 
skating, and games of ball, and copied from the gymnastics 
of the Greeks, notably the "Pentathlon," which he compiled 
from running, jumping, climbing, balancing, and carrying heavy 
weights. 

Among his disciples were Salzman and Guts-Muths, Jahn and 
Spiess in Germany, Pestalozzi and Fellenberg in Switzerland, 
Nachtegall in Denmark, and Ling in Sweden. 

Salzman, one of Basedow's assistants at Dessau, established a 
school at Schnepfenthal, near Gotha, in 1784, and here Guts- 
Muths received his inspiration. As he himself writes: 

'T entered, when still a youth, the school of Schnepfenthal, 
and thereupon Salzman, its head, conducted me to a place, saying, 

95 



96 EXERCISE IN EDUCATION AND MEDICINE 

'Here are our gymnastics; within this Httle space we amuse our- 
selves daily with five exercises, though they are still in their rudi- 
ments.' " 

It was here that he wrote his first book, entitled "Gymnastics 
for the Young" (in 1793), the first German manual of gymnastics. 
He afterward wrote a book on plays and games, which is still a 
classic, as well as a third on manual training. 

Many private and a few public teachers began to introduce 
gymnastics into their schools, and in 1799 Nachtegall established 
a private gymnastic institute in Copenhagen, at which Ling had 
his first lessons in gymnastics. 

Guts-Muths had two distinct aims, which may be stalejl in 
his own words as — "(i) Work in the garb of youthful play, and 
(2) a system of exercise having bodily perfection as their aim." 
The first of these principles appealed particularly to Jahn, while 
Ling worked more in the spirit of the second. 

Friedrich Ludwig Jahn was born in 1778, in the village of 
Lanz. He was a man of aggressive, restless, and self-sufficient 
disposition, quick-witted, but capricious in his reading. His 
career as a student was wild and irregular, and, owing to quar- 
rels with the members of the student societies at Halle, he 
became a wanderer from university to university. From Halle 
he went to Jena, where he was forced to leave the university 
and become a private tutor, directing his pupils' studies and 
partaking in their sports. His first publication, on the promo- 
tion of patriotism, appeared in 1800, and showed his tendency 
to engage in popular agitation. For the next ten years he roved 
about, working at his book on German nationality. In this 
book he extolled the value of bodily exercise, and seized upon the 
idea of making physical training a dominant force in national 
regeneration. 1 

In the spring of 181 1 he opened his first "Turnplatz" in a 
pine forest on the outskirts of Berlin. Friesen, whose untimely 
death by assassination he deeply lamented, and others of his 
admirers and pupils, aided in its management. From the first, 

^ Fred. E. Leonard, P. E. Rev., vol. x, No. i. 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 97 

vigorous and war-like games were assigned a leading role and 
special costumes were adopted. Their badge bore the word 
"Turnkunst," and the figures "9-919-1519-1811." 




These figures served as reminders of Hermann's rout of the 
Roman legions, under Varus, 9 A. d., the introduction of tourna- 
ments into Germany, 919 a. d., the last of the German tourna- 
ments, 1519 A. D., and the revival of "Turnen," or turning, in 1811. 

In a year the number of turners rose to 500. Jahn and Friesen 
organized a German union, hostile to all foreign rulers, and ex- 
tended it to the' students of various German universities. In the 
war of hberation members of this union were the first men enrolled 
in the famous free corps of cavalry, where Jahn commanded a 
company recruited by himself. 

In the five years preceding 18 16 he labored incessantly, 
writing and publishing his book, "Die deutsche Turnkunst," 
which sums up his aims and accomplishment. In speaking af 
the beginning of his work he says: "Love to my fatherland and 
my own inclinations made me a teacher of youth. During the 
beautiful spring of 18 10 a few of my pupils began to go out with 
me into the woods and fields on the hoHday afternoon of Wed- 
nesday and Saturday. The number increased at the various 
sports and exercises. Thus we went on until the dog-days, 
when the number was very large, but soon fell off again. But 
there was left a select number and nucleus who held together 
even during the winter, with whom the first turning ground was 
opened in the spring of 181 1 in the Hasenheide." 

In this work he pays willing tribute to Guts-Muths, the main 
source of his inspiration. 

In 18 19 plans were perfected for establishing turning grounds 



98 



EXERCISE IN EDUCATION AND MEDICINE 




-i P=H 



throughout Prussia in connection with the schools, but because 
of a murder committed by one of the turners, to which pohtical 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 99 

significance was attached, the student societies and Turnvereins 
were put under the ban as being hot-beds of KberaKsm. Jahn 
was arrested, as well as Francis Lieber, a youth of nineteen, one 
of his oldest and most favorite pupils. Lieber was exiled, and 
chose the United States for his new home in 1827. He came with 
a recommendation from Jahn for the express purpose of taking 
charge of a gymnasium in Boston, where he also estabHshed a 
swimming-school. 

Jahn's case dragged on for nearly six years, but he was 
acquitted in 1825, although with certain restrictions. In 1840 
he was finally released and awarded the iron cross in recognition 
of his service during the war of liberation. Though he issued 
many pamphlets showing his continued interest in turning, his 
declining years were passed in poverty and obscurity. His last 
publication appeared in 1848, entitled "Schwanenrede" (swan 
song), closing with these words: 

"Germany's unity was the dream of my awakening Hfe, the 
morning glow of my youth, the sunshine of my manhood, and is 
now the evening star which guides me to eternal rest." 

The formation of gymnastic societies, however, continued to 
grow, and Turnfests were celebrated, until in 186 1 nearly 6000 
turners took part in them. The movement also spread to Spain 
and France under Colonel Amaros in 1826, to Switzerland, from 
which, indeed, it had originated, and to England under Captain 
Clias, and to Russia and, to a lesser extent, to Italy, who have 
founded their gymnastic systems on German ideals. 

The German System has appealed very strongly to the Slav 
race, and every five years, up to the war of 19 14, as many as 
10,000 gymnasts have taken part in the great Sokol g3annastic 
display at Prague, dressed in their white and blue, while at the 
last fete, 6000 women gymnasts were on the field at one time. 
This Sokol festival had grave political significance, however. 
It was the Pan-Slavic cry for freedom from threatened German 
domination over Bohemia, a cause championed by the hero of 
every Sokol, Francois Palacky, the historian. 

At present it is as common to find a Turnverein among 



lOO 



EXERCISE IN EDUCATION AND MEDICINE 



German colonists and peoples of German extraction as cricket 
and athletic sports among Englishmen living abroad. 

The Turnfests at Frankfort and Leipsig had 30,000 turners in 
line, drawn from every land to which there has been German im- 
migration. The exercises, which continued for six days, opened 
by a mass drill of about 20,000 men. Although all the societies, 
drawn from distant lands, had never performed together before, 
the exhibitions were faultless. On succeeding days group com- 



■--'.■T^e 



Him fi OS K KD ,' I' 

'V - -4 ,1 — > — ,-v.c,- 










Fig. 44. — A mass drill of school-children at the Turnfest, Frankfort, 1908. 



petitions and drills were given by children (Fig. 44) and by picked 
squads representing their societies, with individual and group 
competitions on the horse, horizont3,l and parallel bars, running, 
and vaulting. Prizes in the form of wreaths and diplomas were 
given to the successful societies and competitors. 

The turners place great emphasis on mass work, and the 
social sfde has not been neglected. For a time they ceased to 
be political clubs, holding themselves entirely aloof from the 



THE GERMAN SYSTEM OF PHYSICAL TRAINING lOI 

consideration of party questions, but the national importance 
of the societies has never been absent from their minds. 

They are divided into two main sections: boys from seven 
to sixteen years and men. Classes are subdivided in squads, 
each squad being led by a "fore turner," whose business it is to 
make the members of his squad as expert as possible, and, above 
all, to secure to each an erect form and aggressive carriage of the 
body. 

The introduction of the German gymmastics into the school 
system was the work of Adolph Spiess, a Hessian, born in 1810. 
He was influenced by Pestalozzi and trained in the methods of 
Guts-Muths. In 1829 he became acquainted with Jahn, and in 
the following year, while still a student, formed a class of boys at 
Giessen, and made a beginning by teaching what is known as 
common exercises, the simultaneous performance of movements 
in response to the word of command, either with or without the, 
aid of apparatus. He is sometimes called the creator of gym- 
nastics for girls. These gymnastics he introduced into the, 
pubHc schools of Burgdorf, in Switzerland, where he became 
acquainted with Froebel. They include free gymnastics, dumb- 
bell drills, exercises on the suspended ladder, and see-saw, 
besides running, jumping, and swinging. 

In 1848 he returned to Germany, and at Darmstadt carried on 
special normal classes to train assistants for his work, until his 
death in 1858. He was highly successful in teaching g3nmnastics 
to the girls of his schools. 

He applied his principle of common or class exercises to the 
apparatus work, as well as to the free movements, and made 
use of music for all suitable rhythmic combinations. His distinct- 
ive work was to systematize German gymnastics and to adapt 
them to pedagogic purposes and methods. 

The problem of training teachers was early recognized, and 
the Royal Central Gymnastic Institute was finally opened in 
Berlin, under the joint control of the ministers of war and edu- 
cation, after two unsuccessful attempts. Captain H. Roth- 
stein, of the Prussian army, was placed at its head. Rothstein 



I02 



EXERCISE IN EDUCATION AND MEDICINE 



was a warm partisan of the Swedish system of gymnastics as 
developed by Ling and his followers, in distinction to the Jahn- 
Eiselen system, and early antagonized the turners by banishing 
the horizontal bar and parallel bars from the institute. This 
act gave rise to a long and bitter controversy in which gymnasts, 
medical men, and university professors took an active part, 
notably Professor Virchow and Du Bois-Reymond, who savagely 
defended the German system and the bars, declaring that if the 
parallel bars had not already been invented they would be a 







r 


f? " 




^ 


M 


r -^ ^ 4 


^^; 


k 

1 


.'fe4\ 


r 






^^M 




1 


P 


R,^IL^: J^ 


^^^^ 




i- 


r " 


l^^^mi 




» 



Fig. 45. — The Russian gymnasts in a memorized drill founded on German principles 
(Olympic Games, Stockholm, 1912). 

necessity. In 1862 a commission of the most eminent medical 
men declared that the bar exercises, from a medical point of view, 
should not be excluded. As a result of this Rothstein left the 
Central Institute, and died in 1865. 

Gymnastic instruction in the elementary schools was made 
obligatory in 1862 in many of the cities of Germany, and is 
taught by teachers specially educated for this duty, there being 
now more than 1500 trained teachers in Berlin alone. 

The exercises are carefully adapted to the age and sex of the 
pupils. The youngest pupils — from sLx to ten — engage in a great 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 



103 



variety of simple games, easy, free movements, marching, jump- 
ing, and climbing exercises, and the fundamental exercises on the 
gymnastic machines. These exercises grow more complicated 
and difficult for advancing age, and the expertness of the boys in 
the upper classes is often astonishing, fencing being taught in 
the upper schools. Singing is almost always combined with 
gymnastic instruction. 

Outdoor games have been 
accorded a place in the Ger- 
man system from the first, 
but interest in them has in- 
creased to an extraordinary 
degree from the year 1891, 
when the Central Committee 
for the Promotion of Youth- 
ful and Popular Sports in 
Germany was organized under 
the presidency of Baron E. 
von Schenkendorff. Facilities 
for school games have been 
provided, and provision has 
also been made for their 
management and mainten- 
ance. The movement result- 
ing in the American Play- 
ground Association may be traced to the labors of this committee 
and its distinguished president. 

The invitation to hold the Olympic Games in Berlin in 19 16, 
and the engagement of an American coach, Doctor Alvin Kraenz- 
lein, to instruct the Sports Clubs in track and field athletics, 
marked a new emphasis on athletic competition which, although 
present, has always been kept in the background among the 
turners, and the introduction from England of cricket, foot- 
ball, and rowing has still further distracted attention from the 
more purely gymnastic side of exercise which had up to this time, 
almost entirely absorbed the Teutonic mind and body. 




Fig. 46. — Typical pose in German wand drill. 



I04 EXERCISE IN EDUCATION AND MEDICINE 

It must always be remembered that the voluntary athletic 
activities of American and English young men are in Germany 
replaced to a great extent by the arduous and practical military 
training that occupies the best hours of the best years of their 
lives, and has been responsible for the marvelous efficiency 
of their army as shown in the war of 19 14. 




Fig. 47. — Typical swing and balance exercise on the parallel bars. 



The introduction of German gymnastics in America began 
with the arrival of Dr. Follen, a German exile, at Harvard, in 
1826. The Boston Gymnasium in Washington Gardens seems to 
have been the first public gymnasium of any note in the United 
States. 

In 1827 Dr. Francis Lieber, already referred to, succeeded 
Follen. Gymnastic grounds were established at Yale, Williams, 
Amherst, and Brown about the same time, while a dozen or more 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 1 05 

schools followed suit. This movement, however, was short-lived, 
and closed about 1830, when both Dr. Follen and Lieber left the 
field and followed other pursuits. 

The subsequent history of German gymnastics in America is 
that of the growth of German immigration and the establish- 
ment of the Turngemeinden in large American cities, such as 
St. Louis, Milwaukee, Philadelphia, and Cincinnati. The 
Normal College of the North American Gymnastic Union, 
estabHshed in 1861, and now conducted at IndianapoHs, is 
graduating educated teachers trained in this system by courses 




Fig. 48. — Typical circling exercise on horizontal bar. 

extending from one to four years, and the official organ of the 
movement, a monthly, called "Mind and Body," carries on an 
active campaign to introduce physical training into the school 
system and disseminate knowledge on the subject. 

Wilham A. Stecher, its editor and director of physical edu- 
cation in the schools of Philadelphia, divides the German system 
into six large groups or classes: 

1. Tactics, embracing marching in all its forms. 

2. Free elcerclses, embracing all forms with hand apparatus, 
like short and long wands, dumb-bells, rings, and clubs. 

3. Dancing steps, principally for girls, including all the move- 



io6 



EXERCISE IN EDUCATION AND MEDICINE 



ments from the simple gallop to the most complicated forms 
executed by expert dancers. 

4. Apparatus work on the horizontal bar, parallel bars, long 
and side horse, buck, suspended rings, ladder, poles, rope, round 
swing, see-saw, balance board, swinging board, pulley-weights, 
storming board, and vaulting table. 

5. Track and field work, such as high, broad, and deep 
jumping, hop, step, and jump, running, hopping, putting the shot 
or stone, throwing the javelin or discus, lifting and putting up 
of iron weights and stones, pole-vaulting, swimming, skating, 
fencing, boxing, wrestKng, and shooting. 




Fig. 40. — Typical vaulting exercise on German horse. 



6. Games and plays, the enumeration of which would take 
too long. The first collection of games was published by Guts- 
Muths in 1793. 

The exercises for children are divided into six or eight grades, 
to correspond with the number of years in the common or 
grammar schools. 

Inclusive as it is of almost all forms of indoor and outdoor 
activity, the characteristic apparatus that will always be asso- 
ciated with German gymnastics, because invented and most 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 107 

largely used by them, are the parallel bars, where the typical exer- 
cises are those in which the weight is supported by the arms in 
vaulting and balancing. The horizontal bar, the glorified limb of 
a tree, in which the weight is also supported by the arms in circles 
and levers; and the vaulting horse, borrowed from the days of 
chivalry, on which circles, vaults, and pirouettes are practised 
and carried to a high point of development, the weight being 
again supported by the arms. 

Exercises on these machines emphasizes the development of 
the muscles of the shoulder-girdle by the almost constant use of 
the arms in supporting the body weight, and in this, together with 
the large use of music to govern the rate and rhythm of the free 
exercises done in classes, lies the main difference between the 
gymnastics that are known as "German" and those derived from 
other sources. Singing and turning are inseparable, especially 
with the children, and the system has become more cosmopolitan 
of late years to fit the local conditions and national temperament 
in America. They now may be said to include everything except 
the medical apphcation of exercise and massage, which has been 
left entirely in the hands of the Swedes. 

For full bibliography, see Bibliographie des gesamten Sports, 191 1, Weiss- 
bein und Roth; mit einem Vorwort von. Geh. Reg-Rat., Prof. Dr. Zuntz, Veit 
& Company, Leipzig, 191 1. 



CHAPTER VIII 

THE SWEDISH SYSTEM OF GYMNASTICS 

The Swedish system of gymnastics had its first impulse from 
patriotism, as was the case with the German, but in the hands 
of its scholarly founder it became much more finished as a gym- 
nastic system, and comprises recreative and school gymnastics, 
military g5niinastics, and, m^ost distinctive of all, medical gym- 
nastics, or the application of movement to the treatment of dis- 
ease. 

Peter Henry Ling, its founder, was born in 1776, two years 
before the birth of Jahn, in Smaland, one of the southern prov- 
inces of Sweden.^ A dreamy, imaginative boy, he entered the 
Latin school at Wexio, where he distinguished himself in his 
classical course by his mental ability, strong individuality, un- 
yielding will, and reckless enterprise. He was suspended or ex- 
pelled from this school, along with some companions, on account 
of a breach of discipline. Leaving Wexio on foot, he seems to have 
wandered for some years in Sweden, Denmark, Germany, France, 
and even England, acquiring the languages of the countries in 
which he sojourned, and we find him, in 1801, enrolled as a volun-, 
teer in the naval defense of Copenhagen against the English. 
Here he remained for ten years, becoming a skilled fencer under 
the instruction of Montrichard, a French refugee, from whom he 
obtained a diploma endorsing his ability to give instruction in 
the art. While there he visited and attended the gymnasium of 
Nachtegall, and recognized the national importance of the new 
art, striving to classify and develop its practice according to 
anatomic laws and to give it the precision of mathematics. 

In the fall of 1804 he returned to Sweden, to act as a sub- 
stitute for the aged fencing master of the University of Lund, 

^ Fred. E. Leonard, P. E. Review, Dec, 1904. 
108 



THE SWEDISH SYSTEM OF GYMNASTICS lOQ 

whom he soon succeeded. He also taught gymnastics and riding, 
and appHed himself dihgently to the study of anatomy and 
physiology, putting his conclusions into practice in the system 
of fencing taught to his pupils. The new exercise became pop- 
ular, and it was not long before interest in it and in his gym- 
nastics spread beyond Lund. Invitations to introduce the double 
art were received from Gothenburg, Malmo, and Christianstad, 
where he gave instruction during the summer vacations in the 
arts of swimming, fencing, the saber, and gymnastics. 

The eight years of his stay in Lund were also fertile in literary 
activity, for it was then that he first began to know and love the 
Scandinavian mythology, and to compose patriotic poems in 
French, German, Danish, and Swedish. One of his poems, 
"Gyfle," deals with the loss of Finland, which the Swedes bit- 
terly deplored. These plays and poems show the intensity of 
his patriotism and his desire to see his countrymen strong in body 
and soul, with power to meet her enemies. Fervid patriotism 
was the inspiring motive of his poems and his gymnastics alike, 
though in the latter he saw a practical means of restoring the 
health as well as of developing the physique of the race to defend 
the fatherland. During these eight years he thought out the 
principles upon which his later work was based, seeking first to 
understand the human body and discover its needs, and then to 
select and apply his exercises intelhgently with these needs in 
view. 

He conceived the idea of opening in Stockholm a central 
institute based on the one already in operation in Denmark for the 
training of teachers of gymnastics for the army and school. He 
took as his pattern the institute of Nachtegall, in Copenhagen. 
His plan was successfully carried out, and the school was opened 
in 1814 on the site occupied ever since. Here he equipped the 
necessary rooms, gymnasium, fencing hall, and offices, in some 
old buildings which had once belonged to a cannon factory. 
By increased grants from the Government he was soon fur- 
nished with an assistant, and two others were added from time 
to time, until, in 1830, he had three. 



no EXERCISE IN EDUCATION AND MEDICINE 

Ling believed that gymnastics had a rightful place in educa- 
tion, medicine, and national defense, and almost from the start 
instruction was given in these three branches. In spite of a good 
deal of jealousy and opposition he continued to teach fencing and 
gymnastics to the Swedish army, under the sympathetic encour- 
agement of Bernadotte, who afterward reigned as Charles XIV. 
When it was shown that the French and Prussian soldiers were 
being drilled in bayonet fencing, his method of teaching this 
exercise was investigated and chosen in preference to all others, 
and it became an established part of their regular training. 

In 1836 he published a manual of bayonet fencing for use in 
the army, and another of gymnastics, in which he found it neces- 
sary to limit the exercises to simple forms that required little or 
no apparatus. 

He commenced the development of medical gymnastics after 
the first year of the Institute in Stockholm, against bitter opposi- 
tion on the part of conservative physicians. 

His school gymnastics comprised only a few stretching move- 
ments, sometimes assisted or resisted by another pupil, but with 
little apparatus, the Swedish educational gymnastics in its present 
form being a comparatively recent growth. 

During all this time his literary activity was intense, and 
always in the realms of mythology and the ancient legendary 
history of the Scandinavian race. His literary labors were re- 
warded by membership in the Swedish Academy, where he also 
received the grand prize. The title of professor was conferred 
upon him, and he was decorated with the Order of the North 
Star. His collected writings fill three large volumes, of which 
only about 350 pages have to do with gymnastics. 

From his first marriage he had one surviving daughter, Jetta, 
and by his second wife, three of his seven children became teach- 
ers of gymnastics — Hjalmar, Hildur, and Wendla, the first two 
at the Central Institute. In 1839, after some years of impaired 
health, he died and was succeeded at the Central Institute by 
Branting and Georgii, who, in company with Dr. Liedbeck, one 
of his pupils, and husband of his daughter Jetta, arranged his 



THE SWEDISH SYSTEM OF GYMNASTICS III 

literary remains for publication. The year after his death they 
published his principles of gymnastics in the incomplete and 
often fragmentary form in which he left them, a treatise begun 
as far back as 1831.^ This book, after an opening section devoted 
to the laws of the human organism, takes up in order the princi- 
ples of educational, military, medical, and esthetic gymnastics, and 
closes with a few pages of miscellaneous suggestions and comment. 

Ling's system was constructed in the light of the physiology 
of his day, which often sounds fantastic in the presence of modern 
discoveries. His physiology with regard to the nature of Hfe, the 
laws of organic unity, and the relation of parts seems quaint to 
modern thinkers, and is not easily translated into the scientific 
terms of to-day. His work relating to gymnastics is, however, of 
a thoroughly practical nature, and he must have been a most 
inspiring teacher. He never completely expressed his scheme of 
esthetic gymnastics, and the school gymnastics were the life- 
work of his son Hjalmar. 

Immediately after his death B ranting was appointed director, 
a position he retained for twenty- three years. A student of the 
largest medical college in Sweden, a fluent linguist, and a wide 
traveler, he devoted himself with marked enthusiasm to medical 
gymnastics in accordance with the theories of his predecessor, 
and brought that department to a high degree of perfection. He. 
insisted that the beneficial effects of exercises were due not alone 
to changes produced in the muscular system, but mainly to the 
influence exerted upon the nerves and blood-vessels — a novel 
view at that time. He also worked out a terminology which, with 
a few changes, is still employed in Sweden. At this period the 
work of the institute began to awaken the attention of other 
countries. Two Prussian army officers. Lieutenant Rothstein 
and Techow, were sent from Germany to Stockholm to take the 
regular course of instruction, and Rothstein afterward wrote 
extensively on the Ling system. His connection with the Berlin 
Central Institute has already been alluded to in the previous 

^ Gymnastikens Allmaund Grunder (1840). Translated by Richard F. 
Cyriax. P. E. Review, Dec, 191 2; Jan., 1913; May, 1914. 



112 EXERCISE IN EDUCATION AND MEDICINE 

chapter. He endeavored to model it on the pattern of the Swedish 
school, but without its department of medical gymnastics. 

Many other foreigners came for visits of varying duration — 
physicians especially were attracted, among them Dr. Matthias 
Roth, of London, the father of Bernard Roth, F. R. C. S., whose 
work on scoliosis is referred to elsewhere. 

Among the teachers at the Central Institute were Karl 
August Georgii (1808-8 1), a lieutenant in the army, who became 
head teacher in 1839, giving instruction in anatomy and the three 
branches of practical gymnastics. He pubhshed a treatise on the 
Ling method of kinesitherapy and physical education. Three 
years later he removed to London, where for. twenty-eight years 
he had a private institute, teaching fencing and school gymnastics 
in addition to his medical work. Here he published, among other 
things, a biographic sketch of Ling, the "new movement cure," 
and a book on rational gymnastics. B ranting' s successor was 
Colonel Gustave Nyblaeus (1816-1902), under whose director- 
ship the course was increased from one year to two years, and 
practical gymnastics finally reorganized, with its three sections, 
educational, medical, and military, each having a head teacher 
and a second teacher. 

John Hartelius (1818-96), a graduate of the institute, who 
afterward completed a course in medicine, took charge of the 
medical gymnastics in 1864. During his term he wrote, besides 

ail manuals on anatomy, physiology, histology, and hygiene, 
a larger work on medical gymnastics, which was translated widely. 
He also founded and edited the "Tidskrift i Gjonnastik," a 
magazine devoted to gymnastics, contributing many articles on 
his own and related subjects. 

To Hjalinar Frederick Ling (1820-86) Swedish educational 
gymnastics is largely indebted for its present form, and the school 
gymnasium for the nature and arrangements of the equipment 
now in use. At first a pupil of his father, he afterward attended 
Claude Bernard's lectures on experimental physiology at the 
Hotel Dieu, in Paris, and lived for a year in Berlin, whither he 
went to introduce the Swedish method of medical gymnastics. 



THE SWEDISH SYSTEM OF GYMNASTICS II3 

After his return to Stockholm, in 1864, he was assigned the sec- 
tion of school gymnastics. His task was to devise new forms of 
apparatus adapted to the need of the school, and to so arrange 
them that large numbers could exercise at the same time. He 
largely increased the number of useful exercises, and brought them 
within the reach of every pupil. He is the originator of the group- 
ing of exercises known as the "day's order," which is so charac- 
teristic of the Swedish system. Famihar with the whole range of 
gymnastic literature, he was an industrious compiler, and left 
behind a carefully arranged collection of nearly 2000 pen draw- 
ings of positions and movements used in gymnastics, all made 
by his own hand. He died in 1886. 

Hjalmar Ling's successor was Lars Mauritz Torngren (1887), 
A third year was now added to the course. His writings included 
a manual of gymnastics for the navy and a book on school gym- 
nastics. The second teacher in the section on school gymnas- 
tics, Major Karl Silow, has been very active and successful in 
the work of his department, and has made further improvements 
in the construction and arrangement of apparatus. Hartelius 
was succeeded in 1887 by Robert Murray, also a regularly trained 
physician, in the section of medical gymnastics, and Colonel 
Viktor Gustaf Balck about the same time assumed control 
of the section on military gymnastics. The latter has been 
an ardent advocate of outdoor and other sports for the young, 
and has been active in organizing societies for their cultivation, 
editing a series of a dozen illustrated volumes devoted to a 
description of their various forms. He founded, in 1881, the 
"Sporting Times," and has been the most enthusiastic promoter 
of those popular gymnastic societies that have spread the fame of 
Swedish gymnastics to other countries, accompanymg squads of 
his fellow-countrymen to exhibitions in Brussels, Paris, London, 
Copenhagen, and Berhn. He was president of the Swedish 
Committee of the Olympic Games in 191 2. 

The Swedish gymnastics were introduced into the United 
States by the late Baron Nils Posse, and Boston has been the 
center from which their influence has spread. A most active 



114 EXERCISE IN EDUCATION AND MEDICINE 

propaganda was started by Baron Posse, who lectured and 
wrote widely on the subject, and as a result the Boston Normal 
School of Gymnastics was founded in 1889 by Mrs. Mary 
Hemenway, to provide the means whereby those masters and 
submasters who desired it might make a thorough study of the 
Ling system for the benefit of the schools. This resulted in the 
introduction of the Swedish system of gymnastics in the 
Boston public schools in 1890, under the direction of Hartwig 
Nissen. After two years' service. Baron Posse resigned and 




Fig. so. — Free movement by the Danish girls team, Stockholm, 1912. 

was succeeded by Claes Enebuske, he himself founding a normal 
school, the Posse Gymnasium, which is still carried on by the 
Baroness in Boston, giving a two-year course in both theory and 
practice, and including a wide range of subjects in its curriculum. 
The Boston Normal School has now become a department of 
Wellesley College for women, with Amy Morris Homans as 
first dean. 

Although Swedish gymnastics have been considerably modi- 
fied by Ling's successors, and particularly by his son, the develop- 
ment has closely followed the lines marked out by its originator. 



THE SWEDISH SYSTEM OF GYMNASTICS 



"5 



He classified movements into groups, as they were directed 
to the muscles of the trunk, head, arm, or leg, making use of a 
table which was the forerunner of the present "day's order." 
His first table consists of three order movements, afterward 
increased to five; then follov>rs, sixth, a leg movement; seventh, 
an arm movement; eighth and ninth, leg movements; tenth and 
eleventh, arm movements — all of a respiratory nature. His 
tables also show a forecast of the progression which is the other 
characteristic of the Swedish system. 




Fig. SI. — The Royal Guard of Sweden at work in the gymnasium (Lefebure). 



His long experience in training military cadets strongly in- 
fluenced the character of his theories. E. M. Hartwell justly 
observes that Swedish gymnastics still bear witness to their 
semimilitary origin. Ling's peculiar aims are more completely 
reflected and his methods more fully embodied in the physical 
training of recruits and soldiers than in any other department of 
Swedish gymnastics. The military element in Sweden has in 
turn served to add dignity to physical training as a profession, 
and to raise the intellectual and social standing of gymnastic 
instructors. 



il6 EXERCISE IN EDUCATION AND MEDICINE 

The three distinguishing points of the Swedish system of 
educational gymnastics are: 

1. The day'^ order. 

2. Gymnastic progression. 

3. The use of the word of command for movements instead 
of imitation. 

The exercises of the day's order are always arranged under 
the following ten classes, each of which can be made more diffi- 





Fig. 52. — Introductory exercise position, Fig. 53. — Span bending at the stall bars, 

neck firm. 

cult or complicated, as is deemed advisable by the progress of the 
pupil. The order is: 

1. Introductory exercises, class formations, facings, and 
marching steps (Fig. 52). 

2. Span bendings, consisting of backward flexions of the 
trunk, executed by the arching of the spine, done either with or 
without apparatus (Fig. 53). 



THE SWEDISH SYSTEM OF GYMNASTICS II7 

3. Heaving movements, designed to cultivate elasticity of 
the chest and increase respiratory power. Usually exercises of 
hanging and climbing (Fig. 54). 

4. Balance movements, or exercises of equilibrium, requiring 
high co-ordination, rather than force, and especially directed to 
improve the posture of the body (Figs. 55, 56). 




Fig. 54. — Heaving movement on ropes. 

5. Shoulder-blade movements, exercises for the arms, usually 
done in some position producing isolation of the chest and head, 
the object being to raise and widen the chest (Fig. 57). 

6. Abdominal exercises, bringing into play the muscles 
of the abdomen, and by that means acting upon the diges- 
tive organs and improving the natural support of the viscera 
(Fig. 58). 

7. Lateral trunk movements, consisting of rotation, sidewise 
flexion of the trunk, and exercises derived from these types (Fig. 
59). 



ii8 



EXERCISE IN EDUCATION AND MEDICINE 




Fig- SS- — Balancing exercise. 



^^ 


i u 


■'■]' 


m 


1^., 




^i^^l^ ».^. ^ 


% ' 11 




x. i 


1 ^^^ 




Ill 


j^ 




^HK^LJk^ r^^^H 


^ • H 


Iv ■ «.J» J 


.1' '-'izB i;; 


m 






Ka^^t^l 


wmm 


i^ 




[g^ySi 


m^'v. 


M^^ 




4 


ayoP^'^^^jy 




,..._ . i 



Fig. 56. — A typical balance exercise for equilibrium (.Swedish ladies' team, Stockholm, 

,1912). 



THE SWEDISH SYSTEM OF GYMNASTICS 



119 




Fig. 57. — Shoulder-blade movement. 




Fig. 58. — Abdominal exercise on stall bars. 



I20 EXERCISE IN EDUCATION AND MEDICINE 

8. Leg movements, for the purpose of relieving the engorged 
veins of the fatigued legs (Fig. 60). 

9. Leaping and vaulting over a string or Swedish horse (Fig. 
61). 

10. Respiratory exercises, accompanied by movements to 
assist respiratory activity. They are designed to restore normal 




Fig. 59. — Lateral trunk movement. 

respiration after the more active work that has gone before 
(Figs. 62, 63). 

This order may be shghtly varied by introducing, after the 
balancing exercises, marching and running, or by introducing a 
series of heaving movements after the lateral trunk rnovements, 
thus increasing the groups in a day's order to twelve. The 
Stockholm Gymnastic Society introduces marching, running, 
and gymnastic games into the day's order, and by repeating the 



THE SWEDISH SYSTEM OF GYMNASTICS 121 

mmmr 




Fia. 6c. — Let: movements. 




Fig. 6i. — Leaping exercise. 



shoulder-blade and abdominal movements brought the divisions 
of the day's order up to fifteen. 



122 EXERCISE IN EDUCATION AND MEDICINE 




Fig. 62. — Respiratory exercise No. i. 




Fig. 63. — Respiratory exercise No 2. 



THE SWEDISH SYSTEM OF GYMNASTICS 



123 



The order of exercises is the basis of the Swedish method, and 
may be depicted graphically by the following diagram, repre- 
senting a forty-minute lesson period, the height of the curve 
showing the intensity of the effect on the circulation and respir- 
ation. The height of the Hne for the abdominal exercises is 
probably insufficient in this diagram (Fig. 64). 

The apparatus used differs in certain important respects from 
that of the Germans. The parallel bars, horizontal bar, and 
spring-board are eschewed, while the horse is modified in form; 
instead of these are introduced stall bars, boom, climbing ladders, 
and poles, while much use is made of the incKned rope and the 



Leaping exercises. 




lOmimila 



S' 



Fig. 64. — Diagram of the day's order, showing the time devoted to each division and the 
amount of effort required for each (Lefebure). 



balancing board. The exercise table or plinth, used in medical 
gymnastics, is either flat or adjustable to different angles. 

The Swedish system considers of first importance the regions 
affected by the exercises; the Germans consider the attributes 
the exercise cultivates. 

The movements are classified according to the effect they have 
on the body, and not as in the German system, according to appa- 
ratus. The Swedes use various forms of apparatus to secure a 
physiologic result. The Germans see what variety of exercises 
can be done on each piece of apparatus. 

Ling intended that his system of gymnastics should form a 



124 



EXERCISE IN EDUCATION AND MEDICINE 



complete method of physical education designed to develop 
all the bodily powers, but he did not live to complete his inten- 
tions. In the fragmentary state in which his plans were left, 
and in which they have remained in the hands of his followers, 
Swedish gymnastics as a complete system are open to the criticism 
that insufficient emphasis is laid upon endurance, and excessive 
emphasis laid on the constant voluntary attention of the pupil. 
Their accuracy makes them peculiarly efficient in correcting the 
tendency of school children to assume abnormal and hurtful 




Fig. 65. — Drill of the Swedish team, Stockholm, 1912 — a typical exercise. 

postures, and the stress laid upon the proper carriage and move- 
ments of the trunk undoubtedly serve as an antidote to the evil 
effects of the school desk. 

It may be justly said in criticism, however, that the stress 
laid upon an overcorrected carriage of the body gives the ' 'pouter- 
pigeon" posture, with hollow back and protruded chest, which is 
unnatural, stiff, and leads to strain in the lower back. The free 
movements are static rather than dynamic, consisting of a series 
of long-sustained exhausting poses. ^ 

Little account is paid to the importance of rhythm in the 
' Culture Physique, Francis Heckel, Masson, Paris, 1913. 



THE SWEDISH SYSTEM OF GYMNASTICS 



125 



movements which are angular and do not follow the long and 
sweeping curves of natural actions. Few of the movements used 
occur in an isolated form in real life. In consequence of this they 
are less interesting than movements based on fundamental 
activities and done in a natural way. The keynote of the system 
is precision, sometimes obtained at the cost of grace. The in- 
terest in a mass drill is more in the extraordinary uniformity 



_r 




-L 



Fig. 66. — The plan of the new gymnastic high-school, Stockholm, showing six gym- 
nasium halls, lecture rooms, amphitheatre, and swimming-pool. On the floors above and 
below are other lecture rooms, laboratories, and library, with dressing-rooms and offices. 
Facing it is the stadium and dressing-rooms for outdoor sports. 



acquired than in the exercises themselves (see Figs. 65 and 57), 
for they demand and exact a discipline of the most rigid kind, 
which gives them a military or soldier-like value and which 
must not. be forgotten. 

Swedish gymnastics are educational because they are pro- 
gressive, definitely arranged according to a fixed law, and re- 
quire a prompt response to the word of cojnmand. To be called 



126 EXERCISE IN EDUCATION AND MEDICINE 

a complete system they must be considerably modified from 
their present form, and include the free outdoor sports and games 
on which so much emphasis has been laid by Colonel Balck who, 
recognizing this lack, has done much to correct it. 

The new gymnastic high-school, which is to replace the old 
building at 19 Hamgatan, Stockholm, will complete the archi- 
tectural group begun by the stadium in which the fifth modern 
Olympic games were held. It will be the most perfect and com- 
prehensive institution in the world for the teaching of physical 
education. Ample provision is made for practice and instrucr 
tion in track and field athletics, sports, and games, as well as 
gymnastics, and the theoretic side will be amply provided for. 

In many cases the gymnastic lesson of the Swedish school 
is now replaced by an hour of skating, long walks, or gymnastic 
games and dancing; and in the training-schools for teachers the 
introduction of dancing steps and other movements to music, 
which may be termed esthetic, is not regarded with the horror 
that it would have excited a few years ago. It may be looked 
upon as the modern development of esthetic gymnastics which 
Ling had in mind, but never worked out. 

The military gymnastics need not be dwelt upon here, as 
they consist largely of fencing with the bayonet, foil, and saber, 
riding, and other military exercises which are not exclusively Swe- 
dish in character, but the medical gjnmnastics, which are so wide- 
spread in their apphcation, deserve a more careful consideration. 

Classification and practice of the movements of massage 
described in another chapter have been largely the work of Swe- 
dish practitioners, and all the duplicate movements were described " 
and named by Ling with extreme exactness, so that the prescrip- 
tion of exercise may be written with clearness and accuracy. 

Plans for the new gymnastic high-school do not provide for 
the clinical teaching of medical gymnastics as heretofore. This 
will in future be carried on in the hospitals instead of in the 
institute as at present.^ 

^ For complete bibliography, see E. F. Cyriax, P. E. Rev., vol. xvii, 447-454; 
and Bibliographia Gymnastica Medica Worishofer, 1909. 



CHAPTER IX 

THE WAR OF THE SYSTEMS IN FRANCE 
THE SEARCH FOR HARMONY AND RHYTHM 

France has been the battleground of ideas on physical 
education for the last one hundred years. Both German and 
Swedish gymnastics have had their day. The revival of athletic 
sports has been a notable event in her history, but it was only in 
the ten years preceding the war of 19 14 that anything like a 
national system in harmony with Latin ideals and tempera- 
ment was taking definite form. 

The pioneer of physical training in France was Don Francisco 
Amaros (i 770-1848), a Spaniard by birth and a cadet in the 
Spanish Army. In 1806 the king established at Madrid a 
Pestalozzian institute, with Amaros at its head. The Napo- 
leonic wars broke up this institute, and in 18 14 Amaros, who 
sided with the French, fled to Paris. He became a naturahzed 
Frenchman, opened a gymnasium in Paris (1818) close to the 
military school. The success was instantaneous, and a great open- 
air gymnasium furnished with apparatus like that of Jahn was 
constructed for military purposes in 1820 with Amaros in 
charge.^ The g5rmnasium continued for seventeen years, and 
was closed in 1837 owing to disagreements with the government, 
but he opened a new gjrmnasium, which he continued till his 
death. He laid the foundation of French military, institute, and 
school gymnastics, devised a great deal of apparatus, and made 
much of singing as an exercise. 

Another man who was instrumental in furthering physical edu- 
cation in France was Phokion Heinrich CKas, born in Boston of 
Swiss and Huguenot parents in 1782, sent to a school in Holland. 

^ See Manual d'Education Physique et Morale, Paris, 1830. 

127 



125 EXERCISE IN EDUCATION AND MEDICINE 

In 1814, as an officer of the Light Artillery, he began free instruc- 
tion in gymnastics to the men under his charge, as well as to the 
boys in the orphan asylum at Berne. He met with great success, 
and in 18 17 moved to Paris, where Amaros had already opened a 
gymnasium. He did not meet with success there and was induced 
to go to London in 1822, where he attained the rank of captain and 
was made Superintendent of Physical Training in the army and 
navy schools, teaching there until obliged to go into retirement 
crippled by an accident. In spite of this he emerged from his 
retirement in 1841, being then almost seventy years old, and 
taught gymnastics in city schools for a year or two, removed to 
Paris, and received the appointment of Superintendent of Gym- 
nastic Instruction in the elementary schools. His books con- 
tain little that is original or of permanent value, and show his 
overweening vanity and his bitterness toward such rivals as 
Amaros. His greatest strength lay in his ability as a practical 
gymnast and teacher. 

Both these gymnasiarchs worked under methods which we 
think of as German, although it all came from the institutes of 
Pestalozzi and Salzman. After the Napoleonic wars France 
was in a desperate state, but overtopping all the political hatreds 
and intrigue that held the country in bondage for the next fifty 
years there was a craving for peace and rest. Over 1,000,000 
men had met untimely death on the battlefield or in camp, 
recruits having been enrolled down to the age of fourteen, and 
the perpetuity of the race was reserved to the weak and infirm 
who had escaped the recruiting officer's net. Even as late as 
1867, one-third of all recruits had to be rejected as unfit for 
military service. It is not surprising then that the attempt at 
the semimilitary form, in which the gymnastics of Amaros and 
Clias were presented, told against their popularity and ultimate 
success. • 

It was not until after the war of 1870 that France really 
awoke to the vital importance of a national system of physical 
training. The first efforts were purely military, but they soon 
found the rigidity of military exercises executed at command, the 



THE WAR OF THE SYSTEMS IN PRANCE 1 29 

prolonged immobility in the ranks, and the violence of some of 
the exercises, unsuited for the best training of children or for 
adults either, and three policies began to gather advocates about 
them. 

One wished to import the Swedish system as it was, another 
to introduce and encourage the athletic games of the English 
and American schools, and a third to discover the laws of move- 
ment, and to work from them to a national system that would 
emphasize self-expression by harmonious movements, grace, and 
utiUty. 

The Swedish system was first introduced in its entirety, and 
became the official system in the Army Training-school at Join- 
ville about 1890, and a strong training school in that system was 
established at Bordeaux under the direction of Dr. Philip Tissie. 
The physical training at the military school at Joinville included, 
however, special gymnastics and athletics, although their calis- 
thenics remain largely Swedish in nature. They added setting 
up drills with the rifle, jumping over heights, obstacles races, 
boxing. La Savate, and jiu-jitsu. 

A somewhat similar but much more practical and perfect 
method was worked out for the navy by Lieutenant Hebert, 
involving such exercises as crawling, springing, carrying, and 
other exercises useful for life at sea. In this, little or nothing has. 
been borrowed from Swedish sources (Fig. 67). 

About 1880 Baron Pierre de Coubertin, after a visit to 
England where the widespread practice of athletic sports in the 
schools is in vogue, essayed the difficult task of introducing them 
into the school system of France. Beginning with L'Ecole Monge, 
he and his associates formed clubs in track athletics, football, 
rowing, and swimming. He interested and allied himself with 
men of influence and enthusiasm in the cause, and was largely 
responsible for the renaissance of athletics in France, which was 
the beginning for the international movement for the revival of 
the Olympic games. Recognizing the tendency to artificiality 
and specialization in athletic competition, he strongly advocated 
keeping as nearly as possible to natural conditions. For example, 
9 



I30 



EXERCISE IN EDUCATION AND MEDICINE 



the jumping over a fixed bar or fence in the high jump instead 
of over a bar that could be easily displaced, the jumping of an 
actual ditch in the broad jump, and running without special 
spikes in the shoes. 

Recognizing the importance of teaching instructors in this 
exercise, the Marquis de Pohgnac established at Rheims a college 




Fig. 67. — Lieut Hebert's method of training against dizziness (Guide Practique d'Educa- 
tion Physique, George Hebert). 

fitted with all the equipment necessary for athletic sports, with 
a track and stadium for exhibitions, and here until the outbreak 
of the war of 19 14 could be seen the best English and American 
methods of training in all field and track sports. While under 
Lieutenant Hebert, the useful gymnastics and physical feats of 
his system were carried to a high degree of perfection. 



THE WAR OF THE SYSTEMS IN FRANCE 



131 



To such a point had athletic 
sports and games been revived 
that France once more began 
to take its place among the 
foremost sport-loving peoples. 
I say "once more" advisedly, 
for as far back as 1637 the 
master of Charter House 
School, England, after a visit 
to Paris, commented in no 
complimentary way on the 
wide extension of sports and 
the prevalence of such games 
as tennis in France, where, he 
says, "it is more common than 
throughout the rest of Christen- 
dom. The country is sown 
with tennis grounds. They 
are more numerous even than 
churches. There are, he de- 
clares, more tennis players in 
France than there are drunk- 
ards in England." ^ 

The most valuable and 
noteworthy contribution to 
scientific physical training in 
France has been the work of 
George Demeny, who has taken 
issue in no uncertain terms 
with the Swedish gymnastics 
as usually taught. As a re- 
sult of his studies with Pro- 
fessor Marey of men and ani- 
mals in motion observed by 

' Sports and Exercises in Ancient 
France, by J. J. Jusseraud. 





Fig. 69. — Curvilinear and harmonious movements (from "Education et Harmonie des 
Mouvements, by George Demeny) . 
132 



THE WAR OF THE SYSTEMS IN FRANCE 1 33 

the cinematograph, he lays down the following as the prin- 
ciples for a natural physiologic system of exercise: 

1 . Movements should be dynamic and not static or jerky. 

2. Movements should be extended, complete, and con- 
tinuous in every possible direction. 

3. Movements should be executed with ease, relaxing the 
muscles that do not directly influence their accomplishment. 

4. The extremities of the segments, like the arm and the 
trunk, describe in space sinuous lines and not sharp angles, ap- 
proaching in direction the center of an ellipse, the figure eight, 
and the spiral. 

5. Movements of the arms or legs are simultaneous or in 
rotation, symmetric or asymetric. 

6. The speed of different segments of the body is in the in- 
verse proportion to their mass. The harmony of a movement is 
the perfect relation between the attitude of the body, the mus- 
cular action, the resistance to be cleared, or the work to be ac- 
complished. 

To summarize, muscular development is obtained by con- 
tinuous working of the muscles from their complete extension to 
their complete contraction. Suppleness is the consequence of 
careful localization of muscular contraction and reduction to the 
indispensable minimum required for a given movement. In 
consequence, he beUeves that the holding of fixed positions is 
exhausting to the nervous system and bad for the circulation. 
Continuous movements are less fatiguing for the amount they 
accomplish, it being easier to change its direction than to stop a 
movement which has begun and to start a new one. He lays 
great stress on the relaxation of antagonistic muscles. From these 
principles he describes the fundamental positions of the legs, 
arms, trunk, and head, with exercises for developing and making 
more supple the body, beginning with the shoulders and arms, 
and always following his rule by using directions that are curvi- 
linear, spiral, or circular. Following these are exercises for the 
legs by the same rules. Many are asymmetric to encourage 
the independence of the right and left side, and so become dififi- 



134 EXERCISE IN EDUCATION AND MEDICINE 

cult feats of co-ordination. This principle of asymmetry in 
exercise, especially where the rhythm of the arms and legs is 
different, is an important part of the "Eurythmics of Jacques 
Dalcroze," to be described later on. 

According to Demeny, physical education should be based 
on the doing of work, on the synthesis of movements into actions 
rather than on the taking and holding of positions, and on 
analysis of movement. This is the point on which he takes issue 
with the Swedes, and it has been the cause of more than one bitter 
controversy. 

The genius of the French people has been strongly indi- 
vidualistic rather than social, and the other extreme from com- 
petitive sports and social games was also voiced fifty years ago 
by Francois Delsarte. 

From time to time certain men arise who, by the force of 
their personality, make a deep impression upon the educational 
world. Whether or not this impression fades after their death 
depends largely upon the vitality of the idea, and the applica- 
tion of movement to the expression of emotion found its voice 
in such a man. 

Francois Delsarte was born at Solesme in i8i i. At the age of 
twelve he was sent to Paris to study painting on china, but his 
tastes carried him in other directions, and he became in 1825 a 
pupil of the "Conservatory," a government institution for 
instruction in acting, music, and the ballet. Here he lost his 
singing voice, and finding himself incapacitated for the stage 
he resigned that career to study and teach elocution and dramatic 
art. After many years of thought and observation he suc- 
ceeded in formulating what he termed the laws of esthetic 
science, which had, he claimed, the precision of mathematics. 
Like all enthusiasts he remained until his death, in 187 1, on the 
eve of a series of discoveries which he felt would revolutionize 
dramatic expression. He never pubhshed an adequate account 
of his researches, but his scattered and fragmentary notes were 
collected by Alfred Giraudet of the Grand Opera, Paris (his 
favorite pupil), and by his daughter Marie (Madame Geraldy). 



THE WAR OF THE SYSTEMS IN FRANCE 135 

Delsarte believed that the perfect reproduction of the char- 
acteristic posture will produce the emotion depicted by the 
actor, and much of his work may be described as an attempt to 
classify and make scientific the empiric rules of the pantomine. 
Positions of the fingers, hands, and legs are named and classified, 
and the expressions of the mouth, nose, and eyebrows are dis- 
cussed in a way that recalls Levator's quaint studies on physiog- 
nomy. 

Gesture as a form of language was his constant study. He 
writes: "When a man says to you in interjective form 'I love, 
I suffer, I am delighted,' etc., do not believe him if his shoulder 
remains in a normal attitude. Do not believe him no matter 
what expression his face may assume. Do not beheve him. He 
lies. His shoulders deny his words. That negative form be- 
trays his thoughts." 

The system designed by him and carried on by his immediate 
followers analyzed form, poise, and gesture, in relation to emo- 
tion. Although much of his writings show the enthusiast and 
the dreamer, his theories were made practical by his strong 
personal magnetism and the social gifts that made him a welcome 
guest at more than one royal table. He himself did not elaborate 
any system of gymnastics to develop the body, but he did teach 
a few principles and exercises necessary for stage-falling and 
other maneuvers in acting. 

The work of Delsarte was brought to the attention of Ameri- 
cans by his most ardent disciple Steele Mackaye, who planned to 
bring his master to America to lecture and demonstrate his 
ideas. Unfortunately, the Franco-Prussian War intervened and 
he died during the Commune. His teachings were made into a 
system of physical culture, the motto of which was relaxation, 
by Steele Mackaye, Genevieve Stebbins, Emily Bishop, Anna 
Payson Call, but when his daughter Marie was induced to 
make a tour in America she found her father's theories so dis- 
torted and misrepresented that she refused to identify his name 
with the movement, and confined her attention to giving semi- 
private lectures and parlor entertainments in elocution and the 



136 



EXERCISE IN EDUCATION AND MEDICINE 




interpretation of La Fontaine's fables according to the rules 
taught by him. 

In its Americanized form, the so-called Delsarte method 
had a great vogue in schools for young ladies, although at 
present it is rather in eclipse, and it is largely through the writ- 
ings of Genevieve Stebbins, Anna Payson Call, and Emily 

Bishop that it has been called 
"the doctrine of limpness." 

Here is a typical exercise 
from Emily Bishop's book: "Hold 
some thought of tranquillity, sit- 
ting erect, so that the feet easily 
rest upon the ground. Look 
steadily at some point in the 
ceiling and take five slow, deep 
breaths. Let the eyehds droop 
heavily and the head sink gently, 
the chin resting upon the chest. 
The back relaxes as far as pos- 
sible , vertebra by vertebra . Last 
of all the hip-joint relaxes, caus- 
ing the head to sway forward 
until it reposes in the lap. In 
returning to the original position, 
reverse the order of action. The 
hip- joint acts first; the motion 
creeps up the back until the 
spinal column regains its double 
curve, which lifts itself to its 
normal poise, after which the 
eyelids languidly open as they 
do in babies, when a little one seems unwilling to surrender to 
heavy drowsiness. 

"This exercise secures a threefold benefit. It develops 
singleness of attention. It partially stupefies the brain, and 
directly soothes the nerves. When accurately done it always 



Fig. 69a. — The right and wrong ways 
of raising an arm according to the Del- 
sartian teaching of relaxation (Cassell's 
"Physical Educator"). 



THE WAR OF THE SYSTEMS IN FRANCE 137 

produces a sensation of sleepiness. Such an exercise should 
occupy from three to five minutes. From three to five repeti- 
tions should produce the drowsiness sufficient to make one 
reservedly relax and sleep." 

Here we have an excellent example of self-hypnotism. Anna 
Payson Call, who also preached the gospel of relaxation, em- 
phasized self-suggestion to overcome the chronic condition of 
nervous tension so frequent among American women, and it is 
this thought that has been a real contribution to physical edu- 
cation, and is suffering at present from over exploitation. 

Delsarte may be said to have been the greatest influence in 
directing attention to the value of muscular action to express 
thought, and his principles continually crop out in other 
schemes of gymnastics. Self-expression by movement was the 
object of his teaching, this intense individualism being charac- 
teristic of the Latin temperament. 

The importance of rhythm in exercise, while considered by 
Delsarte and emphasized strongly by Demeny, has been taken 
as the starting-point of the system of eurythmic gymnastics de- 
signed by Emil Jacques Dalcroze, a musician born in Vienna in 
1865. His musical education was accomplished in Paris and 
Vienna, and later he became musical director of a small theater 
in Algiers, where he became familiar with the pecuHar rhythm of 
Arabian music. From there he returned to a position as Pro- 
fessor of Harmony at the Geneva Conservatory, and wrote a 
series of gesture songs in response to his observation of the 
joy children took in their singing when they themselves illus- 
trated or accompanied it by movements. He noted the feeling 
of unison it gave between the singer and the music. In 1910 
he came to Dresden, where, in the suburb of Hallerau, the late /-e. 
Dr. Wolf Dorn and his brother Harold built a college in which 
he could exploit his ideas. 

The training of advanced and compHcated co-ordination is the 
essence of his method which deals with problems of time, rhythm, 
and movement, not as an accompaniment to music, but as a 
means of expressing it. To do this, he realized that the body 



/ 



138 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. 70. — Beating | canon without expression. The alphabet ("The Eurythmics of Jacques 

Dalcroze"). 

must be sensitized to every rhythmic impulse and trained to 
lose itself in the music. His method falls into three divisions 



THE WAR OF THE SYSTEMS IN FRANCE 



139 




g^^ 





\\ 



J 



Fig. 71. — Beating | canon with expression. The phrase. 

— (first) rhythmic gymnastics, (second) ear training, and (third) 
improvisation or practical harmony. 

These exercises are in their simplest form based upon two 
ideas : 



I40 EXERCISE IN EDUCATION AND MEDICINE 

First, Time is indicated by movements of the arms and 
sometimes the head, distinct movements show time from -|- 
to ^^-. 

Second, The actual notes, their length, grouping, etc., are 
shown by movements of the lower Hmbs, each note, whatever 
its length, is shown by a step forward, a crotchet by a simple 
step, a minim by a step and a knee-bend, a dotted-minim by a 
step with one foot and two movements with the other foot. 
Notes, from groups of six to eight to the beat, up to whole notes 
of twelve beats, can thus be represented. 

The most elementary exercise consists of marking the time 
of a bar with the arms and number of notes with the feet. 
For instance, in a bar of common or four-four time, such as the 
following — 



S 



the arms would beat four and the feet take five steps forward, 
two steps being taken on the second beat. Simple. movements 
to indicate time and notes are learned as one would learn an 
alphabet. The alphabet consists of about twenty gestures with 
the arms, done in many varying combinations. As soon as these 
movements become automatic they are used as units to build up 
more elaborate movements and phrases; thus mechanical repe- 
tition is avoided and more advanced studies in plastic expression 
become possible, but no progress can be made until individuals 
who are rhythmically uncertain, whose muscular system is slow 
or irregular in its response to mental stimuli, have conquered 
their limitations. This part of the training is directed to improv- 
ing the sense of rhythm ; the pupil is taught to arrest movements 
suddenly, to move alternately forward or backward, to spring 
at a given signal, to lie down or stand in exact time to a bar of 
music, in each case with a minimum of muscular effort and 
without losing the feeling for each time unit of the music. 

Variations and new combinations of movements keep them 
interesting, nor can they be done mechanically, because if the 



THE WAR OF THE SYSTEMS IN FRANCE 141 

mind wanders, the pupil at once becomes lost and can find the 
place only with difficulty. He must think quickly and definitely. 
When the elementary exercises are mastered time is beaten in 
canon, one arm being one or more beats behind the other, or 
different times may be beaten by each arm and another by 
the head and feet; for example: four different times are beaten 
simultaneously, a truly remarkable feat of co-ordination for either 
young or old. 

Dalcroze did not start out deliberately to express feelings and 
emotions by movements of the limbs as did Delsarte, but it is 




Fig. 72. — "Elation" expressed by movement (from Dalcroze College Journal). 

one of the results of his method, and these rhythmic movements 
undoubtedly help to deepen the intellectual and emotional hfe 
of the pupil. As the pupil advances, the more mechanical move- 
ments of the arms become softened and rounded, and more and 
more expressive of the rhythm and emotion of the music. The 
whole body thus becomes a means of plastic expression. (See 
Fig. 71.) 

The other aspect of the work at Hellerau, ear training and 
improvisation, fascinating points of the general system, must 
not tempt us from our main subject, but from the standpoint 



142 EXERCISE IN EDUCATION AND MEDICINE 

of physical training his work presents certain well-marked 
differences from gymnastics as usually taught. In most systems 
of gymnastics the movements are done at a definite rate, which 
does not vary. Dalcroze continually changes the tempo to 
accustom the pupil to the ready adjustment to a changed speed, 
for when a movement is rapid, balance is less important and 
certain muscular contractions are instinctively ehminated. 
When it is slow, a greater nuinber of co-ordinated contractions 
must be introduced. If we are to avoid clumsiness in changing 
from one to the other, both must be made interchangeable. 
Most gymnastic movements are prearranged and not spon- 
taneous, and so give us no natural or artistic expression. Indi- 
vidual interpretation of the movement is strenuously cultivated 
by Dalcroze. He attempts to systematize the natural rhythms 
of the body, and by constantly repeating them to render them 
automatic in every degree of speed and energy; in other words, 
to give the brain definite rhythmic images. Looking upon the 
body as the best instrument for expression, he finds music as 
essential for this purpose as the bow is to the violin. This 
method gives the pupil musical expression rather than musical 
knowledge, and Dalcroze seeks to reclaim that natural poise of 
the body so often lost. 

The place of this system in physical education will naturally 
be with those to whom the sense of rhythm is of overwhelming 
importance. Gestures and attitudes of the body have always 
been used instinctively by artists in singing, but in the more com- 
plicated forms of music like grand opera, the importance of 
rhythmic movements for expressing the sentiment and emotion 
of the music must naturally be of vital importance. No one who 
wishes to cultivate a sense of rhythm and the finer co-ordina- 
tions of the neuromuscular system could find a better way for 
doing it. 



CHAPTER X 
PHYSICAL EDUCATION BY ATHLETICS 

The exercises described in the last few chapters are more or 
less artificial in character, and in proportion as their artificiality- 
is marked their hold on the average youth is lessened, i 

Running, jumping, throwing, catching, climbing, fighting, 
and tusshng are the natural activities to which boys turn for the 
development and expression of their physical powers. It is these 
activities codified and regulated that we call athletic sports. 

The group games demanding co-operation, as described in 
Chapter VI, are a development of the individual contest, and 
wrestling under its many rules — Grseco-Roman, catch-as-catch- 
can, collar-and-elbow, glima, and jiu-jitsu — is but a regulation 
of the natural desire to pull, push, and throw an opponent, 
according to the temperament of the people who practice 
it. Ball games, like tennis, cricket, baseball, lacrosse, hockey, 
hand-ball, and paloma, are developed from throwing and strik- 
ing a small ball with a club of some kind. The indiscriminate 
kicking of a football has developed into soccer, and the more 
highly organized carrying game of Rugby school, from which' 
the college game in America originated, has been carried to a 
point hitherto unsurpassed for tactics and team work.^ 

Teachers have been slow to recognize the possibility and ne- 
cessity of directing the play instinct for the better education of the 
child. Too frequently it is ignored or looked upon as a nuisance. 

In America athletic sports recall to men not yet old only 
the Caledonian gathering, where the few professional athletes 
went from place to place collecting and dividing the meager 
purses, and the practice of running, jumping, and throwing 
weights was the accomplishment of but few. 

The present high development of athletic competition is a 

^ Football, the American Intercollegiate Game, Parke H. Davis. 

143 



144 EXERCISE IN EDUCATION AND MEDICINE 

long stride from such primitive picnics. It is within the last 
hundred years that records of any kind have attracted notice. 
The "Rugby Crick Run" was first mentioned in 1837. Games 
were held at Sandhurst in 1840, steeple-chase, sprints, scurry 
and hurdle races at Eton in 1845, followed rapidly by Woolwich, 
Marlborough, Cheltenham, Durham, and Oxford and Cambridge 
from 1852 to 1857. A year later "Bell's Life" speaks of the 
revival of "good old English sports." Scotland followed with 
a University Union in 187 1. Occasional professional athletes 
came from America to England and flashed like meteors across 
the athletic firmament. George Seward, of New Haven, in 1844, 
ran his disputed 100 yards in nine seconds in England, and Deer- 
foot, in 1836, ran in mocassins his 10 miles in fifty-one minutes 
and twenty-six seconds. 

It was not until 1858 that the Amateur Athletic Union^ was 
formed of fifteen clubs for the practice and encouragement of 
sport. The London Athletic Club had preceded it by ten years, 
and the collegiate body soon followed. 

The first American Intercollegiate games were held at Sara- 
toga in 1875. At that time athletic competition was not dis- 
tinguishable from horse-racing, if we may judge from the letter 
received by the committee of that meet from President Buchan, 
explaining why the University of Vermont was not represented 
in the sports. He explained that the students were for the most 
part swinging the scythe in the hay fields, or handling the com- 
pass and chain on the railroads at the time the regatta and 
sports were held, and he concludes by saying, "though they are 
poor they are proud, and would regard it as beneath the dignity 
of a free-born Vermonter to expose their muscles in public like 
gladiators in the amphitheatre for 'Mrs. Morrisey' and other 
high-born dames to bet on. If you will get up a contest in some 
honest and useful work and insure us against the intrusion of 
gamblers and blacklegs, we will engage to be represented. Mean- 

^ History of Amateur Athletic Union, Schroeder, Springfield College Thesis, 
191 2; Physical Training in Athletic Clubs, Augustus Maier, 1904; Rise of Track 
Athletics in Colleges, T. E. Jones' Thesis, 1904. 



PHYSICAL EDUCATION BY ATHLETICS I45 

while we must plead that we are too busy, too poor, and too 
proud." 

Athletic sports took strong hold upon the imagination of the 
students, but their educational possibilities were not grasped by 
many of the faculties, and their wayward organization grew up, 
untempered by the riper experience of older men, rank with those 
abuses and extravagances of which the critics of athletic sports 
still complain. 

Within the last ten years, college after college has taken 
over the athletic training of its students and incorporated it 
into the regular college work, providing equipment in buildings 
and playgrounds, skilled direction, and academic credit for the 
regular practice of this form of exercise, and there is now a 
close resemblance between the athletic education of the Spartan 
or Athenian boy and the youth who is educated at the English 
pubhc school or American preparatory school and college. 

At Sparta the boy was taken away from home at seven and 
put in a boarding-school of about sixty-four boys, where rough 
contests with his fellows rubbed off the individual peculiarities 
and brought out a national type. Among the Spartans the 
education was almost entirely physical. Scouting was taught 
by the foraging expeditions to which they were early introduced, 
a most valuable training for their future military life. 

Riding, hunting, and swimming were systematically taught, 
as well as boxing and wrestling, although the Pancration, which 
corresponded to rough-and-tumble fighting, was early discour- 
aged. They had a game of football which had a close resem- 
blance to actual fighting, and, although they opposed specializa- 
tion in athletics, they were systematically pugnacious. Similar 
schools were provided for girls, although they took their meals 
at home. They shared in the sports of the gymnasium, wrestled, 
ran and swam, threw the discus or javelin, and even raced on 
horseback. They also indulged in a rhythmic drill, a dance to 
the music of the flute. As a nation they deified pluck and endur- 
ance just as boys do to-day, and used it to train a standing army 
of which every citizen was an efficient member. 



146 EXERCISE IN EDUCATION AND MEDICINE 

The Athenian boy, on the other hand, went to school daily, 
taking his meals at home. He was accompanied by his attend- 
ant slave, called a pedagogue, and after his lesson in Uterature 
and music he was taken to the palestra for his athletics. In- 
stead of the scanty one-half hour or hour allowed by our grudg- 



Fig. 73. — Scene in Palaistra, showing athletes with halterers, discus, javelin, and strigil, 
and the pick-axes for loosening the ground (from a Kylix at Munich, attributed to Euphro- 
nios). 



ing boards of education, he had from three to five hours in the 
open air, spending the greater part of it in purely athletic ex- 
ercises. The physical education of the Athenian was athletic 
in character. The casting of the javelin and discus, sprinting 
and running long distances, jumping with dumb-bells, boxing, 
punching the Korykos, or punching-bag, wrestling, and the 



PHYSICAL EDUCATION BY ATHLETICS 



147 




Pankration were studied and practised in turn, and the bath 
and massage concluded his day. OverspeciaHzation was com- 



148 



EXERCISE IN EDUCATION AND MEDICINE 



bated by the Pentathlon, or all-around contest in running, 
jumping, throwing the discus, the javelin, and in wrestlmg.^ 

The widest application of athletics to educational ends is 
found in the colleges, pubhc school athletic leagues, and munic- 
ipal playgrounds, described fully in subsequent chapters. 

At Amherst, a college of 600 students, there are twenty pales- 
tra^ for football and baseball. At Andover (see Fig. 74) and 
Lawrenceville every boy is drafted into the athletic teams and 
given opportunity for play." At the University of Pennsylvania 
a system of intensive athletics is practised in which the various 




75 



-"Taking the first hill" in an intercollegiate cross-country championship run 
at Princeton (Edward R. Bushnell). 



activities are used for their educational value (see Fig. 157), 
while extensive tracts are laid aside for athletic purposes at Wis- 
consin, Princeton, Harvard, Yale, and Chicago. 

Cross-country running, hare and hounds, and steeplechase, 
so characteristic of the English public school boy's education, 
have been largely responsible for making athletics popular 
throughout the British Isles. It was after a visit to Rugby that 
Baron de Couberton was inspired to advocate the introduction 
of running, cricket, and football into the French schools, where 
such activities were at that time opposed or prohibited. He 

1 Kenneth J. Freeman, The Schools of Hellas. 

2 "Control of Competitive Sports in Secondary Schools," G. S. Lowman, P. 
E. Rev., vol. xii, 141. 



PHYSICAL EDUCATION BY ATHLETICS 1 49 

founded an International Olympic Committee and systematic 
international competition in sport had its beginning. Within 
the last twenty years the interest in organized athletic sports 
has spread so rapidly that the word Olympic has taken on a new 
meaning, and is used for games in Manila, Pekin, Tokyo, Stock- 
holm, London, Paris, St. Louis, as well as for the classic festivals 
of Greece, and the International Federation of Sports adopted a 
uniform code of regulations at Paris in 19 14 to minimize the 
constant friction caused by the different interpretation of rules 
and varying methods in practice, and to standardize the dis- 
tances and implements of athletic competition. (See Hand- 
book, Spaulding's Sports Library.) 

A field and track are necessary for the practice of athletics. 
The track should be constructed to insure rapid and free drainage. 
A safe rule is to have a 12-inch foundation of rough stone and 
clinkers covered with 6 inches of clay and cinders, and ending 
with a top dressing of cinders and clay firmly rolled down. This 
allows for free drainage and also for a springy surface. The 
width of the track should be about 18 feet, and it should have a 
straightaway on one side of 220 yards if possible, but never 
less than 100 yards. The turns of a circular track need not be 
banked for running, and the back stretch may be narrower than 
the homestretch. 

The field contained within this track should be provided with 
jumping pits of earth loosely dug up. The take-ofif for the broad 
jump should be a joist of wood sunk flush with the ground 
approached by a 30-yard path of cinders. For the high jump 
and pole vault, standards should be supplied capable of being 
raised to 14 feet, since the pole vault record has now passed 
13 feet. Shot putting and hammer throwing require a 7 -foot 
circle, with a footboard at the front for the shot-put. A heavy 
wire cage, 20 feet in diameter, should surround three sides of the 
circle to reduce the chance of accidents in the hammer-throw. 
The javeHn, whi^h is much used in Europe, has taken but little 
hold in America, although its inclusion in the Olympic program 
will probably increase its popularity. 



ISO 



EXERCISE IN EDUCATION AND MEDICINE 



Detailed training for special events cannot be covered here/ 
but reference to p. 79 will show the various qualities culti- 
vated by each of the athletic events. 

The usual program in track and field athletics consists of 
running short and long distances, jumping for both height and 
distance, pole vaulting, throwing the discus, the hammer, the ^6- 
pound weight, the javelin, putting the shot, and hurdle-racing. 

The sprinting distances are 100 and 220 yards, and in train- 
ing for them special emphasis should be placed on the concen- 




Fig. 76. — The starting pose for a sprint race. (Copyright, 1902, R. Tait McKenzie.) 



tration of attention at the start, the cultivation of the proper 
stride, and the determination required for the final spurt. It is 
the usual custom to practice the starts frequently when pre- 
paring for a sprint, and Murphy always had his sprinters run 
less than the full distance in practice.^ Great care must be 
taken during cold weather to prevent sprains and ruptures in 
muscles imperfectly warmed by preliminary movements. A fair 
runner should cover the loo yards in 12 seconds; a good one, in 
io4 seconds; the world's record is 9| seconds. In the 220 

^ Athletic Training, M. C. Murphy, C. Scribner's Sons; and Track Ath- 
letics in Detail, Harpers. 



PHYSICAL EDUCATION BY ATHLETICS 



151 



corresponding times would be 26, 24 seconds, and the record is 
2i| seconds. 

The J mile, or 440 yards, is the hardest race on the program. 
It is really a sprint, although endurance is a most important 
factor in it. This is one of the most popular of the track events, 
but it should not be practised by boys under seventeen. In fact, 
it is better to wait another couple of years before running this 
exhausting distance. A fair runner should complete the dis- 
tance in 60 seconds; a good runner, in 54 seconds; the record is 
47 seconds. 




Fig. 77. — ^The finish of the icxj-meter race, Stockholm, igi2. 

The ^, I, and 2 mile are the usual distances for long races. 
They are primarily tests of endurance, and are run as much as 
possible on the ball of the foot in order to avoid the shock and 
consequent muscle soreness due to running flat-footed. The 
breathing is done for the most part through the mouth. It is 
in the longer distances, the i and 2 miles, that the phenomenon 
of second wind described in a previous chapter takes place. 
In the mile it usually occurs in the third quarter, and is a great 
relief to the respiratory apparatus. It was Murphy's practice 
to let athletes training for these races run about three-fourths 
of the distance in practice, relying on the excitement of the con- 



152 



EXERCISE IN EDUCATION AND MEDICINE 



test to carry them the entire distance to the finish. A fair run- 
ner should be able to run the half in 2 minutes 15 seconds, the 
mile in 5 minutes 10 seconds, and the 2 miles in 14 minutes; 
a good runner should be able to make them in 2 minutes 5 
seconds, 4 minutes 50 seconds, and 10 minutes 30 seconds; the 




Fig. 78. — The finish of the 400-meter race, Stockholm, 1912. 



records are: for the ^ mile, i minute 514 seconds; for the mile, 4 
minutes i2f seconds; and the 2 miles, 9 minutes 9 seconds. 

The winning of the race from Marathon to Athens by a 
Greek at the Olympic games in 1896 resulted in a craze for 
the so-called Marathon races. Clubs, newspapers, and com- 
munities organized them for boys and men of all ages and con- 
ditions, and but little care was taken in the prehminary training 
or in the conduct of the races themselves. 



PHYSICAL EDUCATION BY ATHLETICS 



153 



The great exhaustion resulting from the 25-mile run cannot 
but be detrimental to boys who have not attained their full 
growth. Even in the seasoned and mature athletes the strength 
of the competitor must be husbanded, and the distance he runs 
in practice gradually increased from 5 to 12 or 15 miles, followed 
by plenty of rest. A much more sane and beneficial form of 
long-distance running is found in Paper Chases or Hare and 
Hounds, where the runners vary their pace frequently by climb- 
ing fences, walking over ploughed ground or through woods. 




^ Fig. 79. — The American team training for the Marathon race, Stockholm, igi2. 

Runners should go out for practice in packs, the pace being set 
by some one experienced in setting a moderate pace. 

Competitive walking has been discontinued largely because 
of the difficulty of judging fair heel-and-toe walking in which the 
heel of the forward foot must be down before the toe of the rear 
foot leaves the ground. The pace is unnatural and difficult to 
acquire, but no exercise in its non-competitive form has been so 
widely enjoyed. 

The hurdle-race is confined to two distances, 120 yards over 
ten hurdles, 3 feet 6 inches in height, the first and last being 
placed 15 yards from the start and the finish, with a lo-yard 



154 



EXERCISE IN EDUCATION AND MEDICINE 



interval between each hurdle. The second race is the 220-yard 
hurdles, with ten hurdles 2 feet 6 inches high and 20 yards apart. 
The hurdles are made movable so that striking them does not 
mean a bad fall on the cinders. In the shorter race, practice is 
confined to the method of clearing the obstacle and acquiring 
the three strides between the hurdles. Attention is concen- 
trated on clearing each one as closely as possible without being 
disqualified by knocking down two hurdles in ten. In the low 




Fig. 80. — Clearing the high hurdles in good form. (Photograph by Edward R. Bushnell, 
courtesy of I. C. A. A. A. A.) 



hurdles seven strides are taken before each leap, but being only 
2 feet 6 inches high they are cleared with little disturbance to 
the stride. The most successful hurdlers are usually men of good 
height and length of leg, for the fixed distances cannot be ac- 
commodated to the length of a short man's legs. This is an in- 
stance in which the type of figure must accommodate itself to 
the apparatus used. A fair performance for the shorter distance 
would be 20 seconds; a good one, 17 seconds; the record is i^^ 



PHYSICAL EDUCATION BY ATHLETICS 



155 



seconds. For the longer distance the figures would be 31, 28, 
and 23 1 seconds. 

The broad jumper takes off from an 8-inch joist sunk level with 
the ground and lands in loosened soil„because rough or hard ground 
may turn an ankle or break down the arch of the foot. It is well 
to have the heel of the shoe padded to absorb part of the shock. 
The distance cleared is measured from the take-off to the first 
break in the ground made by any part of the body, so that men 








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|MU| 


oift^^'vi:^-. 


i 


Fm 


MBiriiMfci 


"^^^ 




'r^^^ f^'h^ ■ 


^ 


BHP"^ 


K ' J 


rSSSjJ 


~ " Wfi 


^ 



Fig. 81. — Clearing the low hurdles in good form. (Photograph by Edward R. Bushnell, 
courtesy of I. C. A. A. A. A.) 

are taught not only to measure off their running distance, but 
also to get height and balance in the jump so as to prevent their 
ialKng backward in landing. In the first turnplatz Jahn used 
for the broad jump a ditch narrow at one end and gradually 
increasing in width, the winner being the one who could clear 
the widest point. This approaches more nearly to the practice 
of the broad jump under ordinary conditions. Eighteen feet 
is a fair jump, 20 feet is a good one, and the record is 24 feet 
iif inches. The standing broad jump is measured from the 



156 



EXERCISE IN EDUCATION AND MEDICINE 




( ,(hhI Uiriu Ml I iu' IiiXKul jum|i 







Fig. 83. — Ciood form in the high jump. 



take-ojff to the nearest p')oint touched by any part of the body. 
This is a test of the actual spring of the body much more than 
the running jump in which the question of speed is paramount. 
Ten feet is a good jump, and the record is 11 feet 2 inches. 



PHYSICAL EDUCATION BY ATHLETICS 157 

In the high jump the competitor clears a crossbar, which is 
easily displaced, and alights in soft earth. In this the teaching 
of the technic is most important — the approach, the measure- 
ment of the last few strides, and the method of clearing the bar, 
so that the hips and shoulders may in turn evade the bar. While 
each competitor has some peculiarity of style all his own, the best 
jumpers run at a right angle toward the bar, spring from and 
alight on the same leg, turning in the air and land with face to 
the bar. 




Fig. 84.^The standing high jump, showing the "scissors" style. 

The side or "scissors" jump is universally condemned by the 
.best trainers, although in the standing high jump the competitor 
stands sideways to the bar and clears it in this way. Any style 
in which the head and shoulders go over the bar before the feet 
is prohibited because it is a dive and not a jump. Five feet is 
creditable; to clear 5 feet 6 inches is good, although the record 
stands now at 6 feet 7 inches. 

The pole vault is done from a run, and the body is raised by 
the arms and lifted over a bar on a 15-foot pole of spruce or bam- 



158 



EXERCISE IN EDUCATION AND MEDICINE 



boo. The pole is released while the athlete is in the air and falls 
back as the competitor clears the bar without touching it. Any 
displacement of the bar by the pole or the body counts as a failure. 
Any vaulter should clear 9 feet; 10 feet 6 inches is good, and 
the record is over 13 feet. 




Fig. 85. — The pole vault, clearing; the bar. 



The javelin is thrown from a short run, the weapon being^ 
grasped about the middle. This ancient sport played an im- 
portant part in the athletics of the Greeks. With them it was 
thrown with either hand, and usually by means of a thong or 
amentum, which doubtless increased the throwing distance. 
A fair throw is 100 feet; the record is over 170 feet. Among 
the Greeks it was a practical method of teaching one of their 



PHYSICAL EDUCATION BY ATHLETICS 



159 



favorite methods of attack, but the frequent accidents that 
are reported among them would make it of questionable value 
as a means of exercise, especially as the same muscles are con- 
stantly used in throwing the baseball. 

The discus throw has also come down from antiquity. Its 
style was a result of the flinging of a stone or any other object 
too heavy to be thrown in the ordinary way. The first discus 
was a heavy piece of iron. As now used it is a circular disc^ 
8 inches in diameter, weighing 4^ pounds. It is thrown from an 
8-foot circle and with one or two turns. The absurd and ridic- 




Fig. 86. — Throwing the javelin. 

ulous Greek style, which was at first insisted upon at the modern 
Olympic games, was the result of an attempt to reconstruct the 
ancient method from such fragmentary evidence as the Disco- 
bolos by Myron and certain Greek coins and vase paintings. 
It resulted in a style closely resembling bowling and could never 
have been in use among the ancient Greeks. The "Discobolos" 
undoubtedly threw his discus with a spin of the body toward the 
left, and the modern athlete has instinctively amplified that by 
adding one or two turns borrowed from hammer throwing. It 
is an excellent exercise for balance and strength. A fair per- 



i6o 



EXERCISE IN EDUCATION AND MEDICINE 



former should hurl it loo feet; a good one, 125 feet; the record 
is about 150 feet. 

Throwing the hammer seems to have originated on the village 
greens of Scotland, where the blacksmith's hammer was always 
at hand. As now used the hammer is changed beyond recog- 
nition, consisting as it does of a ball, 12 or 16 pounds in weight, 




Preparing to throw the discus. 



connected by a swivel with a wire handle which terminates in 
two triangular wire loops gripped by both hands. It is thrown 
from a 7-foot circle by a spinning movement, and the accuracy 
required in maintaining the balance, making two, or even three, 
rapid turns, is so great that few hammer throwers approach 
reasonably near to perfection. The frequency of accidents 



PHYSICAL EDUCATION BY ATHLETICS 



l6l 



resulting from wild throws have, in consequence, rendered it so 
unpopular that it may yet be dropped from the Hst of standard 
field sports. A fair throw is loo feet; a good one, 140 feet; the 
record is 189 feet. 

The heaving of the 56-pound weight, a ball of iron attached 
by a triangular iron handle, is another throwing contest. At first 




Fig. SS. — Throwing the 56-pound weight. 

thrown by one hand, it soon became the custom to throw it 
from both hands for height against a suspended drum, and also 
for distance. Its devotees soon learned to swing it around the 
head with a movement like the hammer throw in technic, but 
this requires a man of great strength and weight. The record 
is 16 feet 8 inches for height and 38.8 feet for distance. 



l62 



EXERCISE IN EDUCATION AND MEDICINE 



The discus, hammer, and 56-pound weight all exercise the 
pulling muscles of the back and leg, while putting the shot brings 
into action the opposite groups. This feat is a development of 
an old Scottish sport called "putting the shoulder stone," and the 
stone or "shot" of iron or lead has been standardized into weights 




Fig. 8g. — The delivery of the shot in shot-putting. 

of 12 and 16 pounds, the Hghter weight being for school boys 
from fifteen to eighteen. This missile is "put" or shoved from 
the shoulder, the competitor standing within a 7-foot circle. 
Around 4 feet of its circumference is a footboard from the inside 
of which the distance of the put is measured. Any throw in 



PHYSICAL EDUCATION BY ATHLETICS 1 63 

which the competitor oversteps the circle counts as a foul. Much 
time must be spent in learning the movements that lead to the 
final throw. 

These consist of a hop across the circle and a quick reverse 
of the legs after the shot is dehvered, and requires fine co-ordi- 
nation, speed, and balance, as well as strength. Thirty-two 
feet is a fair distance to put the 1 6-pound shot; 38 feet is good; 
the record is over 50 feet. The movement of shot-putting is 
opposed to that of the last three throwing events, so that train- 
ing for one is not a preparation for the other. In fact, it is almost 
impossible for an athlete to show supreme ability in both at the 
same time. 

High specialization in any of these events inevitably places 
competition in the hands of the very few experts if unchecked. 
The less successful drop out, and are content to watch the ex- 
ploits of those whose physical endowment and pertinacity puts 
them in a class by themselves. This tendency can be controlled 
by handicapping the swift or the strong until they are put on a 
level for competition, and also by teaching the movements of 
athletics in classes (Figs. 157, 158) where the awkwardness of 
the individual is not conspicuous.^ 

I. Track Athletics in Detail, Harper Brothers; Athletic Training, M. C. 

Murphy, C. Scribner's Sons. 2. E. J. Hjertzberg, Training for Athletics. 3. 

Greek Athletic Sports and Festivals, E. Norman Gardiner, MacMillan. 4. 
Spaulding's Athletic Handbooks. 



CHAPTER XI 

PHYSICAL EDUCATION IN YOUNG MEN^S CHRIS- 
TIAN ASSOCIATION, CAMPS, BOY SCOUTS, AND 
CAMP-FIRE GIRLS 

In addition to the gymnastic and athletic clubs fonned for 
the practice of German or Swedish gymnastics, or for athletic 
sports, voluntary associations, founded for rehgious or social 
purposes, make use of the desire for a better physique and a 
higher level of physical Ufe to make their membership attractive. 

The longing for outdoor Ufe has dotted the mountain and 
lake shore with summer camps. The imagination of boys has 
been stirred to enthusiasm by the Scout movement, and the 
Camp-fire Girls keep ahve the spirit of romance while making 
their bodies strong, active, and valiant. 

Of all these voluntary organizations. The Young Men's 
Christian Association has had the most far-reaching influence, 
and the inclusion of systematic physical education has added 
the third side to the triangle of mind, spirit, and body, which has 
become their badge. 

The New York City association was the first to establish a 
regular gymnasium in addition to the more purely religious pro- 
gram, as a "safeguard against the allurements of objectionable 
places of resort." In Brooklyn the classes were first conducted by 
'Trofessor" Andrews to the music of his own fiddle. It was not 
rnitil 1870, however, that the systematic education of the body 
was seriously considered as part of the regular program for each 
club, and the association was at once confronted with the diffi- 
cult question of obtaining proper supervision and instruction. 
The applicants for these positions were drawn from the prize- 
ring, the wrestHng mat, and the circus, for the most part. Even 
the occasional ex-college athlete was little better, because he was 
usually a specialist in one branch, and had Httle or no prepara- 
164 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 1 65 

tion for teaching either gymnastics or athletics. The recent 
medical graduate had not had the best training and preparation 
for the cultivation of health habits, and in many cases he was not 
a good teacher. 

A teacher in the physical department of a Young Men's 
Christian Association deals with a floating membership which 
changes completely in three years. The members join at any 
time in the year and are irregular in their attendance. Some 
devote too little time to exercise and desire only the hygienic 
effects. Others are ambitious to become experts. They vary in 
age from twelve to sixty, and must be organized in a dozen 
different classes. About 1880 Robert J. Roberts began his 
lifework as an instructor and trainer of teachers in the gym- 
nastics that he considered peculiarly suited to association 
needs. He championed the light gymnastics of Dio Lewis against 
the heavier work of the weight lifter and the German turner. 
He laid special emphasis on the middle third of the body, design- 
ing his various "liver-squeezing" twists and bends with dumb- 
bells to counteract the sluggishness of sedentary habits, especi- 
ally among business men, and his formula which has since become 
famous was that exercises should be ''short, safe, easy, pleasing, 
and beneficial." In the two years 1886 and 1887 he sent out 
twenty-eight teachers to other associations. 

The increasing need having been demonstrated, the Inter- 
national Young Men's Christian Association Training-school 
at Springfield, Massachusetts, organized a course of train- 
ing for physical directors under Dr. Luther Halsey Gulick in 
1887. The two-year course was soon extended to three years, 
and the school has developed into a well-equipped and effi- 
cient college, with thorough courses in anatomy, physiology, 
theory, and practice of physical education, all given by a 
well-trained faculty, with model class-rooms, gymnasium, pool, 
track and field, and lake for water sports, and a splendid refer- 
ence Kbrary on the subject. Its students and faculty have 
already been responsible for much original and valuable research 
on the history and physiology of exercise, and anthropometry. 



i66 



EXERCISE IN EDUCATION AND MEDICINE 



Another training-school was estabhshed in Chicago in 1890, and 
summer courses and conferences are held yearly at Silver Bay, 
Lake Geneva, and elsewhere to keep directors in touch with the 
rapid progress of their subject. 

The great expansion in the organization of recent years has 
given the Young Men's Christian Association physical director 
the task of meeting the physical needs of almost every boy 
and young man in many communities, both at home and abroad, 




Fig. go. — A swimming class at Silver Bay (from "At Home in the Water," Corsan). 



and his technical training fits him for a place on committees for 
promoting municipal playgrounds and physical education in 
both schools and colleges. In Brazil it is the Young Men's 
Christian Association director who organized and conducts the 
physical exercise of the public schools. In 1908 Dr. Max Exner 
introduced the teaching of physical training in Shanghai, and 
began the systematic education of teachers under government 
encouragement. 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 1 67 

The dark basement gymnasium with which the first build- 
ings were equipped has been discarded, and hght and ventilation 
are now the first consideration in planning the one or two well- 
equipped halls devoted to this department. A medical ex- 
amination is always advised before joining any of the gymnastic 
or athletic classes. This is usually given as a volunteer service 
by a doctor, who is rewarded by an increased acquaintance 
among possible patients. Emphasis is placed on the thorough 



|///////;*f.i7^'tf;^-7;:'pn!Un-!ir>ai.4s?!«i,iurauiftf 




Fig. 91. — Members of the gymnastic class in the Y. M. C. A. of Tien-Tsin, China. 



examination of the heart and lungs and tests of the eyes, ears, 
nose, and throat, while the measurements and strength tests 
that at first occupied a large share of the examination have been 
curtailed and in many cases dropped. 

The program of exercise must be comprehensive to accommo- 
date a membership of such widely varying ages. Boys are not 
small men, physiologically speaking, nor is the boy of twelve a 
pocket edition of the youth of eighteen. The boy must be given 



i68 



EXERCISE IN EDUCATION AND MEDICINE 



exercise that will suit his comparatively small heart and limited 
powers of endurance. The circulation must not be overtaxed 
by long-distance races; his concentration must not be tested by 
too long periods of close attention, for his neuromuscular system 
has not yet ripened nor has he arrived at the age for complicated 
team games hke football or basket-ball. From eighteen to 
twenty-two is the time for team games and competitive ath- 
letics. They are the last years in which he is likely to acquire 
those habits of exercise and personal hygiene that will serve him 




Fig. 92. — School children of Rio de Janeiro under instruction by the Y. M. C. A. 



in adult life. This is the time when he must build up his physical 
powers and endurance by vigorous exercise, bringing into full 
play the heart and lungs. The mature business man, however, 
needs relaxation rather than effort. The exercise must not tax 
his heart and lungs to exhaustion. The recreation games requir- 
ing no great specialization seem best for him. He does not need 
a large amount of exercise, and severe and exhausting work 
should be avoided lest the flabby and untrained muscles be 
strained and stiffened. The lameness following a bout of exercise 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 



169 



quickly discourages an older man who only too often has lost 
the power to punish himself in this way, an ability in which a 
youth glories. 

Most business men live irregular and unhygienic lives. In 
many cases their digestion is disordered from overeating, and 
their nervous system by debauches of work, the abuse of narcotics, 
and irregular sleep. Many of them exercise to correct the slug- 
gishness due to overeating, and many others are sent by their 
doctors to counteract symptoms of overwork and nervous 
exhaustion. 




Fig. g3. — A class of business men in class dancing under Oliver E. Hebbert, Providence, 

R. L 



In gymnastics, the. Young Men's Christian Association has 
borrowed largely from the German and Swedish systems, but 
they have changed them without hesitation to meet more ac- 
curately their conditions. German calisthenic work is designed 
for esthetic effect. The movements are slow, graceful, and done 
with Teutonic precision, and always present a fine effect when 
seen in mass drills. Most of the Young Men's Christian Associa- 
tion drills are jerky and ungraceful and done without adequate 
attention to form. Their devotion to heavy gymnastics gives 
the Germans a mastery over all exercises on the bars and the 
horse, and a grace and form for which one will look in vain in 



lyo EXERCISE IN EDUCATION AND MEDICINE 

most Young Men's Christian Association gymnasiums. Their 
obsession for symmetry makes them repeat with right and left 
hand every movement. With this thoroughness the utiHtarian 
American youth has but Httle patience, and the splendid disci- 
pline of the German classes is but faintly re-echoed. 

From the Swedes the association has borrowed much of their 
emphasis on posture and their corrective work. The slow move- 
ments and strained artificial positions held to count are, how- 
ever, distasteful and difficult and the consequent training of 
attention and discipline is not attained. The members come 
voluntarily and casually. Their interest is superficial rather 
than serious. There is a feverish desire for constant change and 
recreation, a spirit of intolerance for any form of restraint, a 
repugnance to hard and exacting work with a strong leaning to 
utility, which makes the problem of administration at once 
alluring and discouraging. While erect carriage is insisted upon 
and corrective exercises for postural defects enter largely into 
the gymnastic drills, this hook must be baited with a Hberal 
allowance of play. Such games as volley ball, battle ball, and 
indoor baseball, games of comparatively low organization, 
provide adequate muscular activity with the minimum risk, 
and do not require great skill, while the rivalry between teams 
does not diminish with age. The medicine ball, which is used 
in many of them, is well named, and is perhaps the most valu- 
able single piece of apparatus in the gymnasium (see Fig. 30). 

The regular program of exercise is arranged in a day's order 
of seven divisions, ending with a bath and rub down. The 
means employed are free movements, calisthenics, gymnastic and 
athletic apparatus, and play or recreation. The movements of 
caHsthenics aim to secure attention, correct posture, to im- 
prove respiration and control. The gymnastic and athletic 
period cover the activities of the main muscle groups by ex- 
ercises on the gymnastic apparatus. 

The recreation period provides relaxation through gymnastic 
and athletic games in the gymnasium, on the field, or in the 
swimming-pool. The following proportion is used: 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 171 

Calisthenics. Gymnastics. Recreation. 

Per cent. Per cent. Per cent. 

Boys, twelve to fourteen years 20 20 60 

Boys, fourteen to sixteen years 20 25 55 

Employed boys, sixteen to eighteen years 25 25 50 
Clerks and office workers, eighteen to 

twenty-one years • ■ ■ 33 5° 17 

Younger business men, twenty-one to 

twenty-five years 70 . . 30 

Business men, twenty-five years and over 70 . . 30 



In this scheme it will be noticed that emphasis is placed 
on the first two divisions in those whose life is more sedentary, 
and also that the heavier muscular tasks of the gymnasium and 
field are discontinued after twenty-one.^ 

The Young Men's Christian Association has carried the or- 
ganization of the Leaders' Club or Corps to a high state of per- 
fection. In Canada the National Leaders' Corps standardizes 
the uniform and grade of its members and conducts an annual 
examination for membership. The National Leaders' Club of 
the United States also standardizes the course in theory and 
practice. In many cities the association supplies from its 
Leaders' Corps instructors for churches, clubs, settlements, 
and playgrounds, and where it is not possible to get a fully 
trained director these volunteer leaders are widely employed. 
Their practical training is thorough, their interest can be counted 
upon, and they in turn gain valuable experience if they wish 
later to take up seriously the work of physical education as a 
vocation. 

The athletic league of the association, organized in 1896, has 
done much to standardize athletic competition and influence 
for good the athletic life of the young American. The league 
aimed primarily at the harmonious development of the body, 
and for this purpose devised a modern pentathlon, consisting 
of a 100-yard dash, 12 -pound-hammer throw, running high jump, 
pole vault, and i mile run, also an indoor decathlon, consisting of 

^ " Physical Education in Young Men's Christian Associations of North 
America," Associated Press. 



172 EXERCISE IN EDUCATION AND MEDICINE 

marching, calisthenics, parallel bars, side horse, horizontal-bar 
exercises, ^ mile, potato race^ three standing jumps, running 
broad jump, long horse, pole vault. One of these standard tests 
had to be passed before an athlete could speciaKze. While 
this form has been abandoned, it must be looked upon as the 
first of the standards that have been so generally adopted on 
the playground and by the pubhc school athletic leagues to 
encourage all-around development. The official handbook of 
the league (19 13) contains the best definition of the amateur 
yet formulated, namely: 

"An amateur athlete is one who participates in competitive 
gymnastics or athletics for pleasure only, and for the physical, 
mental, moral, and social benefits directly derived therefrom. 
A professional athlete is a person who promotes or participates 
in gymnastics or athletics for any other purpose than the 
above." 

This league now governs about one-half million members 
(1914). The tests for boys, especially in rural communities, 
enables groups, such as schools, Sunday-schools, boys' clubs, and 
other such organizations, to compare their athletic ability by 
means of percentages where they could not meet in actual com- 
petition. The plan and standards as tested by E. L. Allen in 
1910, and revised by Dr. John Brown, Jr., in 1913, are as 
follows : 



OUTDOOR ATHLETIC TESTS FOR BOYS IN RURAL COMMUNITIES, 
BY JOHN H. BROWN, Jr., M. D.i 

SCORING TABLE 

80-pound Class 

Honor 100 Points 

o Points. Standard. Scoring. 

So-yard dash 10 seconds. 8 seconds. 6 seconds. 

Standing broad jump 3 ft. 5 in. 5 ft. 6 in. 7 ft. 7 in. 

Running broad jump 5 ft. 10 in. 10 ft. 14 ft. 2 in. 

Base-ball throw 70 ft. 120 ft. 170 ft. 

^ From Official Handbook of Y. M, C. A. Athletic League, 1913, Spalding 
Athletic Library, No. 302. 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 1 73 



Q^-pound Class 

75-yard dash 13 seconds. 

Standing broad jump 3 f t. 1 1 in. 

Running broad jiunp 6 ft. 10 in. 

Baseball throw 100 ft. 



II seconds. 


9 seconds. 


6 ft. 


8 ft. I in. 


lift. 


IS ft. 2 in. 



ISO ft. 



200 ft. 



iio-pound Class 

100-yard dash 16 seconds. 

Standing broad jump 4 ft. 5 in. 

Running broad jump 7 ft. 10 in. 

Running high jump 2 ft. 8^ in. 

Baseball throw 130 ft. 



14 seconds. 


12 seconds. 


6 ft. 6 in. 


8 ft. 7 in. 


12 ft. 


16 ft. 2 in. 


3 ft. 9 in. 


4 ft. 9 J in. 



180 ft. 



30 ft. 



125-ponnd Class 

100-yard dash 15 seconds. 

Standing broad jump 4 f t. 1 1 in. 

Running broad jump 8 ft. 10 in. 

Running high jump 2 ft. 11^ in 

Baseball throw 145 ft. 

Putting 8-pound shot 15 ft. 6 in. 

Unlimited Class 

100-yard dash 14 seconds. 

Standing broad jump 5 ft. 5 in. 

Running broad jump 9 ft. 10 in. 

Running high jump 3 ft. 3 in. 

Baseball throw , 160 ft. 

Putting 8-pound shot 22 ft. 6 in. 



Points shall he scored on the following basis: 

All dashes for every ^ second better than the minimum 5 points 

Standing broad jump, for every inch better than the minimum 2 " 

Running broad jump, for every inch better than the minimum i point 

Running high jump, for every inch better than the minimima 4 points 

Baseball throw, for every foot better than the minimum i point 

Putting 8-potuid shot, for every 3 inches better than the minimiim i " 



13 seconds. 


II seconds. 


7 ft. 


9 ft. I in. 


13 ft. 


17 ft. 2 in. 


4 ft. 


5 ft. 1 in. 


195 ft. 


24s ft. 


28 ft. 


40 ft. 6 in. 


12 seconds. 


ID seconds. 


7 ft. 6 in. 


9 ft. 7 in. 


14 ft. 


18 ft. 2 in. 


4 ft. 4 in. 


5 ft. 4I in. 


210 ft. 


260 ft. 


35 ft. 


47 ft. 6 in. 



An interesting extension of the athletic work of the Young 
Men's Christian Association is seen in the Far Eastern Olympic 
Games, held at Manila, P. I., in February, 1912, under the direc- 
tion of E. S. Brown, of the Manila Young Men's Christian 
Association, in which China sent 40 competitors, Japan a 
baseball team and some track athletes, and the Philippine 



174 



EXERCISE IN EDUCATION AND MEDICINE 



Islands the rest of the 150 competitors. The regular track and 
held events were held, and a baseball game, pentathlon, and 
decathlon. Great interest was aroused and physical education 
in the schools stimulated. The director of education estimates 
that 300,000 schoolboys are now definitely engaged in some 
form of physical education, and the great play-fields that have 
replaced the moats surrounding the walls of Manila now re-echo 
to the shouts of the players of baseball, volley ball, and other 
athletic games. 




. Q4. — Some savage Igorrote boys playing baseball at Manila. 



The physical activity of the Young Men's Christian Associa- 
tion is not limited to the gymnastics and athletic competition. 
Campaigns of various kinds are started. In one season 50,000 
boys were taught to swim by the association. In one such project 
for summer sports an interesting speaker was secured to address 
a meeting of members on how to enjoy a vacation. The stage 
was set with a tent and camp-fire, a canoe, rods, nets, tennis,, 
racquets, bat balls, and golf clubs. Before the evening closed 
cards containing a list of summer sports were passed to all the 
members with the request to make a mark for their favorite 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 1 75 

sport. The cards were collected, the lists were classified, and the 
different groups were called together. The dozen who wanted 
golf met and appointed a committee to investigate and report 
on what could be done. They found a course furnished by the 
city and organized a group to play on them; and so with boat- 
ing and the track and field sports. All these groups reported at a 
subsequent meeting and a summer of organized sports resulted. 
Camping and trips to the seashore can thus be organized at the 
smallest possible expense. Vacant lots and unused fields can be 
obtained for these purposes and a space that is useless or worse 
is thus turned to good account. 

The Young Men's Christian Association was early in the field 
of establishing summer camps for their membership, a move- 
ment that has grown to enormous proportions. In these camps 
the association director, the playground supervisor, and the 
social worker labor hand in hand, and the city child and young 
man, besides learning to practice all kinds of outdoor sports and 
games, can make excursions into the forest and hills and learn the 
mysteries of woodcraft, scouting, and bush life. The whole 
country from Maine to California is dotted with summer camps. 
Besides those established by the Young Men's Christian Associa- 
tion, churches, and settlements, experimental camps both for 
boys and girls were started by the Playground Associations of 
Philadelphia and elsewhere, and there are numerous camps,, 
the result of private enterprise, where certain school studies may 
be combined with an outdoor Hfe, supervised exercise, and the 
practice of games and woodcraft.^ In fact, the real pioneers 
of this movement were the proprietors of private boys' camps 
who, about thirty years ago, began organizing small groups 
and taking them out to the woods. A conservative estimate 
made by Meylan places the number of boys in these private 
camps at about 50,000. 

Two elements combine to make a successful camp: First, 
the supervision and program of occupation ; and, second, the loca- 
tion and care of the sanitary arrangements. 

^ G. L. Meylan, P. E. Review, December, 191 2. 



176 EXERCISE IN EDUCATION AND MEDICINE 

The site of a camp should be on high dry ground, with a 
moderate growth of pine, if possible, close to the shore of a body 
of water and preferably on a point of land exposed to the pre- 
vaiKng sum.mer breezes. It should be as free as possible from 
mosquitos and flies, and should have an abundant supply of 
drinking-water that is above reproach, and near a farm that can 
supply fresh fruit, vegetables, eggs, milk, butter, etc. (Meylan). 
There should be two roomy buildings with open fireplaces, one 
containing a large sitting room, office, workshop, dark room, etc., 
the other containing the dining room and kitchen. The sleeping 
quarters should be tents, varying in size to accommodate any- 
where from two to ten boys. Small tents are preferable, as 
there is usually less noise and disturbance when the boys wake up 




Fig. gs. — War canoes racing.. Camp Tecumseh. (Courtesy of Dr. George W. Orton.) 



early, although a large tent, accommodating five to ten boys, 
permits the master to exercise closer supervision. Small bunga- 
lows, accommodating six or seven boys and a master, are some- 
times iised instead of tents and have their advantages in rainy 
and cold weather. The sanitary arrangements are of the utmost 
importance. It is customary to have a resident camp physician, 
who makes a thorough examination of every camper at the open- 
ing of the camp. This examination should include height, 
weight, and simple tests of efficiency, with notes on the condition 
of the heart, lungs, and other important organs. The camp 
physician should be on the watch for excessive fatigue, loss of 
weight, lack of appetite, and accidents. He may also give short 
talks on diet, bathing, exercise, and clothing. The daily Hfe 
should include a large amount of physical activity and ten 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 1 77 

hours' sleep, with a rest period after the midday meal. Bathing 
is a very important part of camp life, and a short dip before 
breakfast, a swim of ten or fifteen minutes before dinner, and 
even a third before supper are beneficial. In no case should a 
boy be allowed to stay in the water until chilled. 

Camp life gives the best possible opportunity for teaching 
the management of boats, canoes, and scouting, but they also 
give an opportunity to supervise the diet, hours of exercise, rest, 
and daily occupations of boys in whose homes these things are 
neglected. The drills, outdoor games, and swimming may be 




-Off for a trip. Camp Tecumseh. (Courtesy of Dr. George W. Orion.) 



supplemented by cross-country marches, mountain cHmbing, 
the carrying of packs, sleeping in tents, walking through the 
rain or heat, the best possible means to harden the muscles and 
accustom the boy to standing hardships without whimpering. 
The day's program in such a camp as Dr. George Orton's ''Camp 
Tecumseh," or Dr. Meylan's on Lake Sebago starts with the 
bugle call at 6, short setting-up drill at 6.30, breakfast at 7; de- 
tails of campers attend to their duties about the camp from 8 to 
9, games or study from 9 to ii, swimming and boating from 11 to 
12.30, dinner at i, rest hour until 2.30, baseball, tennis, athletic 



178 EXERCISE IN EDUCATION AND MEDICINE 

sports, canoeing, and walks until 6, dinner at 6.30. After dinner 
the whole camp assembles before the camp-fire for talks and 
singing, and lights are put out at 9. 

This routine is necessarily elastic, and parties frequently go 
off for a day's picnic under a councillor, usually a college student 
whose athletic prowess makes him a natural leader for younger 
boys. Even longer trips of several days may be undertaken by 
groups. 

In 191 1 the Playground Association of Philadelphia estab- 
Hshed two camps in which boys and girls between the ages of 
twelve and sixteen years were eligible for membership. The 
expense was four dollars a week per individual, and one day of 



M 


11 jA. 


t^mmfM 


hM 




^A^^ 


1 


W"f»^^r*WB 




1 




m 



Fig. 97. — Morning gymnastics at camp Tecmnseh (Dr. Orton's camp). 

service a week was required from each camper as assigned by 
the Camp Director.^ 

These summer camps are not merely places to which boys 
and girls may be sent in order to keep them off the streets, but 
like the well-supervised playground, described in the next chap- 
ter, they may be made veritable training grounds for the teach- 
ing of proper habits of rest, sleep, and diet combined with 
gymnastics, athletics, and instruction in natural history. The 
foundation for a good character can often be laid in this familiar 
intercourse of camp life. 

^ The particulars about outfit, regulations, equipment, and program were 
published in the pamphlet of the association, 191 2. 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 



179 



It is in this way that the Boy Scouts and the Camp-fire 
Girls have a real mission to perform. The Boy Scouts were 
founded by Lieutenant- General Sir Robert Baden-Powell, whose 
experience in the Boer War made him realize the helplessness 
of the average city dweller when called upon to take care of 
himseh in the woods or on the plain. He started to train up 
boys in the art of scouting, woodcraft, teaching them observa- 
tions of the birds and beasts, the management of boats, canoes, 
camping outfit, ropes, and arms. In America Ernest Thompson 



IS 


H^p 




WB 


^^^r^^^^^H 


B 


^^^P 


WM 






H 


^%^^^n 


m 


M^^H| 


i 




W*^ 


g 






jHWBp*^^^* -iy '^^B 




/ 




f«v- 


H^^Jfi*' 




1^ 


1 


■ 1 




W0^ 






%yfti 



Fig. g8. — Tomahawk throwing. (Courtesy of Dr. J. C. Elsom.) 

Seton had his band of Seton Indians, to whom he taught the 
art of scouting and the signs of the woods, and with Dan Beard 
and a committee of sympathizers the modern Boy Scout move- 
ment began. It has spread with amazing rapidity, and has 
enlisted the enthusiastic support of every boy who can pass 
the tenderfoot test and scrape up the amount for a uniform, 
which he must buy himself. The movement has been popular 
throughout Europe as well as America, and has done much 
to build up the physique as well as the morale of its members. 



i8o 



EXERCISE IN EDUCATION AND MEDICINE 



The main object of the Scout movement is to teach boys 
to do things for themselves, to cultivate observation, and the 
deduction of results. Its real aim is essentially as patriotic as 
are the gymnastics of Sweden and Germany, and the romance 
of the scout and the pioneer is the peg on which hangs instruc- 
tion in first-aid, tracking, signaling, woodcraft, seamanship, 




Fig. 99. — Boy Scouts on the march. Phihidelphia Troop. (Froni 1914 Year-Book of 

Philadelphia Troop.) 



swimming, and team play. Loyalty to his country is taught 
through its history, and obedience breeds the necessary disci- 
pline. There are eight boys in a patrol, one of whom becomes 
the patrol leader. Three or more patrols form a troop, lead by 
a scout master. The motto is "Be Prepared," and a Scout earns 
in turn the badge of Tenderfoot, Second Class Scout, First 
Class Scout, Patrol Leader, and even Scout Master. 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS l8l 

Badges are given for expert knowledge of rope splicing, 
athletics, drawing, trailing, tent pitching, etc. 




' 1 

1- ,»!l 




WK 




b^- 


^^^^i8S«- - 




#-^^^iS 



Fig. loo. — The ceremonial costuiiic of the Camp-fire Girls. 



While the first idea was military and in Europe the military 
utility must ever be uppermost in the thoughts of its organizer, 
in America every effort has been made to divorce it from every 
military alliance, and the natural history and athletic sides 



1 82 EXERCISE IN EDUCATION AND MEDICINE 

have been made much more prominent. Under wise scout 
masters in many of our cities it has succeeded in turning street 
gangs of roughs into eager and alert scouts, and it has given new 
and absorbing interests to the boys of the village and country. 

The Camp-fire Girls supplement the Boy Scouts without 
imitating them. They came into being to meet the demand for 
something for girls to correspond to the scouting for boys. 

This organization, which owes its beginning to Dr. and Mrs. 
Luther Halsey Gulick, is now three years old, is self-supporting 




Fig. loi. — The bathing costume of the Camp-fire Girls. 

and self-governing, and already 2318 camps have been founded, 
with a membership of 29,012 (October, 1914). 

The dominant idea is to keep alive the fire of the hearth and 
dignify the activities that surround it. Not only is the outdoor 
habit cultivated, but the state of mind that makes for sim- 
plicity of life, physical accomplishment, self-reliance, and co- 
operation. She learns to take long walks and to sleep in the 
open. The conquest of the water is accomplished by canoeing 
and the art of swimming. The Camp-fire Girl must swim 



PHYSICAL EDUCATION FOR YOUNG MEN AND GIRLS 1 83 

100 yards before she is allowed in a canoe, and she must learn 
to upset and right her craft. The care of the body is the central 
part of "Wohelo" {work, health, and love), their call, and just 
as the friendships which boys in their teens formed in the team 
work of their games lead to co-operation based on personal trust 





Fig. 102. — The salute of the crew of Camp-fire Girls. 

and knowledge in men, so girls are forming groups in which the 
spirit of team work and co-operation will appear later in women 
who understand each other, and are able to do team work for 
the home, the country, and the nation. 



CHAPTER XII 

MUNICIPAL PLAYGROUNDS AND BATHS 

City life means biologic death. People multiply like bac- 
teria in a culture-medium until they poison themselves with 
their own waste. Their marriage-rate falls, the birth-rate falls, 
and the death-rate rises, until the race would die out were it not 
kept up by a constant influx from the country and from foreign 
lands. 

The physical degeneracy resulting from city life has been 
graphically shown in EngHsh army statistics by an alarming 
shrinkage in the height and chest measurement of young men 
in London and Manchester, and Germany, early recognizing 
this menace, legislated to prevent the overcrowding of the slum 
districts in her cities and has provided outlets for surplus popula- 
tion when overcrowding occurred. 

A century ago in America only 4 per cent, of the people 
dwelt in towns, while in 1900 more than 30 per cent, were town 
or city dwellers, so that not only must the city be made fit for 
children to Hve in, but means must be taken to lessen the rush 
to the cities. 

Far and wide rural districts have been depleted of their 
population until in many sections there are not enough men to 
exploit the natural resources of the land. Organization of play 
and recreation with adequate opportunities for enjoyment will 
undoubtedly help to check this exodus from the farm.^ 

The segregation of city hfe weighs most heavily on the 
children of all but the rich, and the survival of a strong and 
healthy race depends on providing breathing spaces and play 
for them. Most cities have grown up without having borne 
this in mind, and city councils are now confronted with the 
1 Henry S. Curtis, Play and Recreation for the Open Country, Ginn & Co. 
184 



MUNICIPAL PLAYGROUNDS AND BATHS 



185 



need for buying ground for playgrounds in the most densely 
populated wards where it is most difi&cult to obtain. 




Fig. 103. — City conditions showing need of playgrounds (Playgrounds Association of Phila- 
delphia) . 

A casual visitor in Stockholm cannot but be struck at the 
numerous sand piles scattered about the public parks in which 
the children daily amuse themselves, their mothers and nurses 
being the only supervisors. 



i86 



EXERCISE IN EDUCATION AND MEDICINE 



In London the open spaces of all sizes are eagerly acquired 
for this purpose. Russell Court, Drury Lane, the site of that 
old graveyard so graphically described by Dickens in "Bleak 
House," is now a playground. 

Sporadic attempts for playgrounds in America may be said 
to have begun with the equipment of the Charles Bank G>Tn- 
nasium in Boston in 1886 by the Boston Park Board. It. con- 
sists of a running track, open-air gymnasium, and a small inte- 
rior park with shrubs and grass; at the other end a playground 




Fig. 104. — An improvised shower-bath (Playgrounds Association of Philadelphia). 



for women and children with a small running track around the 
outside. The women's gymnasium is protected from observa- 
tion by a thicket of shrubs. 

In 1898 the John Dickinson Playground was established in 
Philadelphia. It consisted of a city block surrounded by large 
trees, a playground for women and children on one side and one 
for men and boys on the other. On account of lack of super- 
vision and defects in construction the playground was severely 
criticized and finally closed up, and the whole movement received 
a setback until the foundation of the Playground Association 



MUNICIPAL PLAYGROUNDS AND BATHS 



187 



of Philadelphia in 1908, and the establishment of a Municipal 
Board of Recreation in 191 2 to supervise the twenty-four play- 
grounds that have been founded and equipped since then. 




The American Playground Association was established in 1906 
to unite the various local bodies in one great concerted cam- 



1 88 EXERCISE IN EDUCATION AND MEDICINE 

paign to interest every American city in playgrounds and to 
co-operate in starting them; to plan the best equipments for 
various sized playgrounds; to provide model courses in play- 
ground administration for normal schools; to collect books, 
models, photographs, etc., as a reference library, and in general, 
to act as a national consulting board. In almost all cases, how- 
ever, playgrounds have been obtained for a city as a result of 
private initiative. 




Fig. io6. — Municipal playground and swimming-pool, Dayton, Ohio. 

According to Joseph Lee, the plan of interesting people in 
the playground movement is one of concentric circles, the center 
being the pioneer desiring the playground, the first circle consist- 
ing of the people who are interested by him or by her in play- 
grounds and who will actively work to influence others; the 
second circle, composed of the organizations that should be inter- 
ested naturally in the question — women's clubs, Young Men's 
Christian Associations, boys' clubs, associations and charities, 
antituberculosis societies, antichild labor organizations, juvenile 
courts, and trade unions; the third circle, city officials and 
leaders, officers of teachers' associations, and superintendents 



MUNICIPAL PLAYGROUNDS AND BATHS 



189 



of education; while the fourth circle is the mayor and city coun- 
eilmen in their official capacity, who cannot be approached 




Fig. 107. — A wading pool in Fairmount Park, Philadelphia. 




Fig. loS. — Sand pile (Waterview Park, Germantown, Pa.). 



with success until public opinion is aroused to the point of in- 
fluencing their re-election. 



190 



EXERCISE IN EDUCATION AND MEDICINE 



The usual procedure is to map out possible playground sites 
by wards according to population, to collect statistics of acci- 
dents, disease, and juvenile crime, to use in the plea. For 




example, a record of twenty-one months in New York shows- 
forty-six children between the ages of one and sixteen killed by 
automobiles, 140 injured: 20 killed and 17 injured by trolleys^ 



MUNICIPAL PLAYGROUNDS AND BATHS 



191 



104 killed and 23 injured by wagons. With the adequate super- 
vision and provision of playgrounds the greater part of this 
unnecessary loss of life could have been avoided. 

Without playgrounds the rallying place for children is the 
street corner, the railway yards, and the docks. For the older 
boys and girls, the saloon, the pool room, the bowhng alley, 
and the dance hall. The smashing of three windows with as 
many stones becomes the equivalent to pitching three balls 
over the home plate. The stealing of second and third base is 




Fig. no. — A swimming-pool, 42 by 100 ft., floored over as a winter gymnasium, St. 

Louis, Mo. 

replaced by stealing fruit from the stand at the corner and 
outfooting the proprietor. The streets become schools for the 
training of criminals, who would become good citizens with 
adequate opportunity for play under good conditions. The intro- 
duction of playgrounds thus has a direct relation to the reduc- 
tion of juvenile crime. A small neighborhood park, such as 
those on the South Side of Chicago, can be accepted to coincide 
with a 28 per cent, decrease of delinquency within the radius of 
I mile. Over a larger area the small parks have a tendency to 
decrease dehnquency about 17 per cent. 



192 



EXERCISE IN EDUCATION AND MEDICINE 



"In a study of lifty convictions for juvenile delinquency in 
Montclair, the record of each case being carefully analyzed to 
find out just how much of the delinquency was due to faulty 
recreation conditions, twenty-four, practically one-half, were 
due primarily to this cause. In twelve cases the primary 
cause was found to be laxity or lack of home-training or influence 
of companions; even here the matter of recreation conditions 




' Fig. III. — A portable steel recreation house, 20 by 40 ft., divided into two parts for 
boys and girls by a removable petition. Comfort stations, 1 2 by 1 2 ft., of similar construc- 
tion, are divided iiUo four sections containing two toilets and two shower baths (Newark 
Playground Comnussion Report, igij). 



influenced the juvenile delinquency since the bad companions 
were often picked up during recreation hours. "^ 

Many other interesting figures have been compiled by 
Allen T. Burns, dean of the Chicago School of Civics and Phil- 
anthropy, comparing the cost of playgrountl maintenance with 
the cost of handling cases of juvenile delinquency, all of them 
proving it a most profitable investment financially. 

In Philadelphia a gang of youths, known as the "Swamp 

^ Extract from recreation survey of Montclair made by Rowland Haynes, 
field-secretary of the Playground and Recreation Association of America. 



MUNICIPAL PLAYGROUNDS AND BATHS 



193 




Fig. 112. — Portable bath-house used in Baltimore, Md. The outside (courtesy of Play- 
ground Association of America). 




Fig. 113. — Portable bath-house used in Baltimore, Md. The inside (courtesy of Play- 
ground Association of America). 
13 



194 



EXERCISE IN EDUCATION AND MEDICINE 



Poodles," ruled with a strong arm the neighborhood of Sedgeley 
Avenue and Twenty-second Street. An open lot was the favor- 
ite battle-ground for this and several hostile gangs. A year ago 
this lot was secured by the Board of Recreation, equipped and 

manned, as the "Fun Field" Play- 
ground. The "swamp poodles" 
disputed the rights of the new- 
comers to interfere, but after a 
sharp contest and the exercise of 
tact and common sense these once, 
feared bulHes became the self-con- 
stituted guardians of the play- 
ground and helped to supervise 
the attendance of 191,000 children, 
who used the ground during the 
following nine months. 

America is confronted with the 
necessity of teaching the language 
and customs of their adopted coun- 
try to the hordes of foreigners who 
arrive in a constant stream and 
congregate in such cities as Chicago 
and New York. The playground, 
or municipal gymnasium, forms the 
most valuable means for their 
education, and the experience of 
Chicago among the Bohemian, Lithuanian, and Polish popula- 
tion has justified the large annual expense. The dream of Walter 
Besant, in his book "All Sorts and Conditions of Men," has 
come true in the South Park Recreation Center. There the 
people's palaces are supported and paid for by all sorts and con- 
ditions of men, and the opportunities, which cannot exist in the 
home to entertain, to play games, to exercise, to dance, and to 
bathe, are provided at nominal expense. They become more 
than mere baths, playgrounds, and gymnasiums. They become 
civic homes for the people. Playgrounds may be divided into 
three groups — small, medium, and large. 




L 

Fig. 1 14. — -Construction of a swing for 
little children in the playground. 



MUNICIPAL PLAYGROUNDS AND BATHS 1 95 

Numerous small spaces of ground are to be obtained in all 
cities by utilizing vacant lots. They can be transformed into 
playgrounds for children of both sexes, and should be equipped 
with a few small swings, seesaws, and sand pile under canvas 
awning, with toilet facihties and a portable house equipped and 
used as a shelter for rainy weather. (See Fig. 112.) If possible, 
a shallow wading pool should be provided. The expense of such 
an equipment need not exceed fifty dollars, and in many cases 
can be obtained from interested supporters of the movement, 
some of the things being made by the children. 

A typical equipment for a small playground is as follows: 

Cost. 
A lo-foot double swing frame with triangular ends braced and two 

swings $10- $21 

Two children's 6-foot swings with canvas scups for little children to 

swing or sleep in, well protected from sun 10- 35 

Two or three seesaws, with 14-foot boards 5- 10 

Sand box varying in size and shape according to place, filled by one or 

two loads of fine white sand 5- 14 

Awning for protection from midday sun and shelter for rainy weather. . 10-60 

Total cost $40-1140 

Provision must be made for rainy weather as well as bright, 
and the materials used by the younger children for whom such 
playgrounds are especially designed would consist largely of 
kindergarten materials, such as blocks, sand, clay, shells, boxes, 
spoons, cardboard, and such necessary tools as hammer, saws, 
nails, shovels, and buckets. An effort should be made to encour- 
age the children to decorate and beautify these plots as much as 
possible. They should be scattered about the city at distances 
of not more than three or four blocks at the furthest from their 
homes. Small children cannot go more than 200 or 300 yards 
to their playgrounds, and for this reason city parks can be used 
only on rare occasions. Where vacant lots cannot be found 
the back yards of houses can be utilized (Fig. 115), and some- 
times part of a street can be closed for heavy traffic during 
certain hours of the day to permit with safety games and dancing 
on the pavement (Fig. 115a). 

The second type of playground should consist of a piece of 



196 



EXERCISE IN EDUCATION AND MEDICINE 



ground from 2 to 10 acres, with a more substantial shelter con- 
taining a gymnasium and room for indoor games, toilet rooms. 




Fig. 115. — ^The sand modeler at work in a back yard playground. 




Fig. iisa. — Street closed for play, New York. Dancing to the music of a Hurdy Gurdy. 
(Courtesy of Playground Association of America.) 



shower baths, and an ofifice for the supervisor. The ground itself 
should be provided with a wading pool, sand pile or court for 



MUNICIPAL PLAYGROUNDS AND BATHS 



197 




Fig. 116. — The giant stride in use, 




Fig. 117. — Sand pile and wading pfjol at Happy Hollow pla\ ground, Philadelphia. 



198 



EXERCISE IN EDUCATION AND MEDICINE 



the young children, swmiming-pool for those who are older. 
The sand pile here may be extended to the dignity of a garden 






Fig. iiS. — An up-to-date equipment for second type of playground. 




Fig. 119. — Apparatus in use (Gymnasium, Washington Park, Pittsburgh). 

or court fenced in and provided with simple toys, buckets, shovels, 
and building blocks. The sand should be exposed to the sun and 



MUNICIPAL PLAYGROUNDS AND BATHS 



199 



rain, and great care should be exercised to prevent the spread of 
communicable disease through this medium by changing or 
airing it frequently. The center of the field should be supplied 
with fixed apparatus. This consists of a framework of iron upon 
which are suspended ladders, rings, and ropes, as well as per- 
manent sets of parallel bars and horses of varying heights, jump 
stands, giant strides, merry-go-rounds, circle bars, and slides. 




-The ever-popular slide. 

Where the ground is large enough there should be a running 
track surrounding the field. 

These playgrounds are necessarily fewer in number than the 
first type, but should not be more than | mile apart in the 
crowded sections of the city. They are intended for boys and 
girls from twelve to eighteen years of age, with special quarters 
for the younger children. 

With the co-operation of the Board of Education, the school 
yard may well be turned into a playground of this type because 



200 



EXERCISE IN EDUCATION AND MEDICINE 



the schools are placed where the children are thickest. They 
belong to the municipality and have the necessary conveniences 
already installed, with the possibility of using the basement in 
rainy weather. The yards are already enclosed and the janitor 
can look after the apparatus when the ground is not in use by 
the children, prevent wanton destruction, and materially lessen 
the cost of administration, the ground being used summer and 
winter. Boards of education will then be encouraged to enlarge 



f---'- ^ 



SCHOOL PLAYCROtND 



Puauc Scnoot. 







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f^ S^^TibU.B^^ ^ 



Id- 



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Fig. 121. — Type I of playground, combined with school j'ard (Elizabeth Rafter). 

them by securing neighboring property, as has already been 
done in Philadelphia and elsewhere, and both municipaUty 
and school board profit from the combination. In the second 
t3^e of playground a swimming-pool should be provided for 
the older boys and girls, approachable only through a room 
containing showers, and the utmost care should be exercised 
in insisting upon the preliminary shower with soap and water 
before entrance into the pool. Where the ground is large 
enough a running track should surround the field. This may be 



MUNICIPAL PLAYGROUNDS AND BATHS 



20I 



either of clay or cinders, and the best surface dressing should 
consist of clay and cinders mixed. 







Fig. 122. — Armour Square, Chicago, showing diviEion of space for little children, men, and 
for playing ball games, with the recreation building in one corner (Type II) . 



The following equipment is recommended by Mr. Lee F. 
Hanmer. The cost would be about $230, after the buildings 
and pools are installed: 

I shoot-the-shutes. 

4 box swings for small children, under shelter. 

4 sand bins for small children, under shelter. 

4 large swings. 

I horizontal bar. 

3 teeter boards. 

I Jump pit. 

I basket-ball ground and equipment. 

I quoit ground. 

Bean-bags, skipping-ropes, etc. 



202 EXERCISE IN EDUCATION AND MEDICINE 

Facilities for boys and girls from twelve to eighteen years 
should be provided, although provision for the younger children 
must also be made in specially protected parts from which the 
older children cannot dislodge them. 

The following would equip an ideal playground for girls 
of all ages and Httle boys: 

(Size of playground, 200 by 350 ft., 1.60 acre. Capacity, 500 to 600 children.) 
4 sand courts 8 by 16 ft., cement shelves at sides for sand modeling and 
playing jacks. 

1 wading pool, 50 ft. in diameter. 
4 giant strides. 

12 rope swings, 10 ft. high. 

2 sUding boards. 

4 climbing ropes and 4 chmbing poles. 

2 sets (5 each) traveling rings. 

I set basket-ball goals. 

4 vertical ladders and 4 inclined ladders. 

6 teeter boards. 

4 sets ring toss or quoits. 

I cement or wood platform for dancing, 50 ft. square. 

Continuous supply of balls, bats, basket- and volley balls, nets, and bean-bags. 

Approximate cost outside of pool and platform, $1200. 

Pool, 18 in. deep, soft, square, 17 cents per square foot, bottom and sides 7 in. 

thick. 
Platform about 13 cents per square foot, cement. 

An ideal playground equipment for boys and young 
men: 

(Size, 200 by 450 ft., 2.06 acres. Capacity, 300 to 450 boys.) 

1 quarter-mile track. 4 climbing ropes. 

2 high and 2 broad jump sets. 4 climbing poles. 
2 pole-vault sets. 4 vertical ladders. 
30 adjustable hurdles. 4 slanting ladders. 
4 rope swings. i buck. 

3' horizontal bars. i horse. 

2 shot-put sets. I parallel bar. 

2 sets traveling rings (5 each). i set basket-ball goals. 

4 sets flying rings. 4 sets quoits. 

2 trapezes. i stop watch. 

2 giant strides. i revolver. 

Tape, megaphone, continuous supply of bats, balls, etc. 

Approximate cost, $1500. Swimming-pool, 17 cents per square foot. 



MUNICIPAL PLAYGROUNDS AND BATHS 203 

The third type of playground, which has its best examples in 
such places as South Park Field houses in Chicago, Boston 
Common, Central Park, N. Y,, and Fairmount Park, Phila- 
delphia, should be of such size as to allow large numbers of 
children to play at the same time. Here, great play pageants 
may be held and space for innumerable tennis and baseball 
games provided. The smallest should be large enough to allow 
of two baseball diamonds, a j-mile track with apparatus, de- 
scribed in the two previous types, as well as a big swimming- 
pool and field house. 

Such a building should be the social center of the district, the 
spacious hall used for lectures, dances, and other social gather- 
ings. Club rooms, gymnasium for boys and girls, offices for the 
administration should be included. The swimming- and wading 
pools should be large enough to use as a skating rink in win- 
ter. One swimming-pool, in Chicago, is | acre in size, and 
ranges in depth from 3 to 8 feet. It is surrounded by a beach 
of white sand, and the only entrance is through a room contain- 
ing fifteen shower-baths. The pool is hghted and kept open 
until 9.30 in the evening. 

Play itself is neither good nor bad, but it has all the possi- 
bilities of either, so that the profession of playground supervisor 
is one of the most important in the whole range of the teaching 
profession. It has become a distinct specialty in physical educa- 
tion, and besides requiring unusual natural gifts it requires 
thorough technical preparation, which is now provided in most 
good normal schools of physical education. According to recent 
statistics it is taught in 17 schools and colleges as part of their 
curriculum. Courses at Wisconsin and other colleges of the 
Middle West and Pacific slope especially designed for this work 
are largely attended. 

There were 900 teachers and students at the Summer School 
at University of California in 19 13, most of them preparing for 
work as playground supervisors. 

The director of a playground should be a trained social 
worker, with an understanding of the value of exercise and fresh 



204 



EXERCISE IN EDUCATION AND MEDICINE 




MUNICIPAL PLAYGROUNDS AND BATHS 205 

air, with a knowledge of dancing, games, and all varieties of 
industrial work. The supervisor of a small playground for young 
children should be familiar with kindergarten methods. She 
should teach them the simple kindergarten games, direct them 
in their play on the sand heap, modeling or building castles with 
blocks, lead them in singing and dancing games, tell them stories, 
and take part with them in the many natural occupations that 
appeal to young children. This may well be combined with visit- 
ing the children's homes and tactfully instilhng in the parents' 
minds the importance of cleanliness and personal hygiene. It 
is above dispute that the director makes the playground. 

A good course for supervisors should include the practical use 
of play for conservation, for development, and for education; its 
relation to the public health, morals, and ideals; to school, church 
home, and settlement, their seasonal rotation and their applica- 
tion to the varying ages of the children and to the conditions 
peculiar to the school, the playground, the social settlement, 
and the church. The history of the play movement should be 
learned, the administration of recreation systems, including its 
relation to city departments and to other organizations like the 
Boy Scouts, Camp-fire Girls. Planning, equipment, and care of 
grounds should be studied and the organizing and conducting 
of games, athletics, dances, parties, pageants, field work, and 
outdoor hoHdays. 

A typical afternoon's activity on a playground may be gath- 
ered from the program adopted for the playgrounds of Newark, 
New Jersey. The teachers report at 12.45, the playgrounds 
opening at one. The boys and girls are collected during the 
first twenty minutes, and a short talk is given them on some 
subject related to athletics, hygiene, or conduct, followed by the 
salute to the flag. This may be varied by some short story 
selected from the fairy tales, like "Uncle Remus" or the Greek 
legends, followed by a song. It is a moving sight to see a large 
number of children, many of whom have but an imperfect knowl- 
edge of the language, unite in the salute to the flag, which is given 
every day at the beginning of the exercises. All stand at "atten- 



2o6 EXERCISE IN EDUCATION AND MEDICINE 

tion" and repeat in unison, "We the children of many lands who 
find rest under thy folds do pledge our lives, our hearts, and our 
sacred honor to love and protect thee, our country, and the 
Hberty of the American people forever." After the salute to the 
flag the children go through simple marching evolutions, which 
bring them into position for a simple lo-minute drill either 
free hand, with wands, or with other apparatus. After this the 
boys and girls march to their own yards or playgrounds, or if the 
weather is inclement, to the club rooms. The children do most 
of the mechanical work of the playground by clearing it, raking 
it, watering it, digging jumping pits, preparing the baseball dia- 
monds and running track. The girls make the bases for baseball, 
bean bags, and other simple apparatus. The indoor occupations 
consist of kite making, whittKng of boats, swords, playing check- 
ers, the use of the scroll saw, basketry, or weaving. In addition 
to this the girls may do plain or fancy sewing, paper cutting, and 
weaving. The material used is not taken home, and the children 
are urged to finish the work they begin. Where possible, they 
supply their own material and take the finished objects home. 

Out on the playground volley ball is played, also basket-ball, 
playground ball for boys, throwing the basket-ball for distance, 
and dodge ball for boys and girls. 

These may be enriched by many of the games described by 
Jessie H. Bancroft in her book on "Games for Playground, Home, 
School, and Gymnasium" (Macmillan & Co.), the particular 
game used depending on the interest shown after the game has 
been thoroughly tried. 

For the small children kindergarten work runs all day in 
groups, changing periodically. Story telling is one of the most 
popular forms of entertainment, and the works of Hans Anderson, 
Sir George Besant, Maud Lindsay, Louis Carroll have unfail- 
ing interest. For the older children the "Jungle Book" of Kipling, 
the animal stories of Thompson Seton, with such stories as 
Hiawatha, Robin Hood as told by Howard Pyle, the "Wonder 
Book" of Hawthorne, the "Norse Stories" of Hamilton Mabie, 
are all most popular. 



MUNICIPAL PLAYGROUNDS AND BATHS 



207 



Games should be systematically taught and led by the 
director herself. Folk dances are taught the girls in the late 




afternoon. These can be taught either indoor or outdoor accom- 
panied by the music of a phonograph.^ A complete collection of 

^"Bibliography of Folk Dances," P. E. Rev., vol. xiv, 1909; Folk Songs and 
Dances, Cecil J. Sharp (W. H. Gray & Co., N. Y.). 



2o8 EXERCISE IN EDUCATION AND MEDICINE 

these dances with the method of teaching may be found in Miss 
EHzabeth Burchenal's,^ or C. Ward Crampton's,^ book. 

At four o'clock in the afternoon organized and match games 
begin. Teams are organized and progressive tournaments 
arranged in basket-ball, playground ball, volley ball, and base- 
ball for boys, and end ball, dodge ball, and captain ball for girls. 
These give opportunity for teaching sportsmanship, the spirit 




Fig. 125. — A hurdle-race under difficulties. 

of fair play, and obedience to law. The scores of these games are 
posted so that the progress of each team can be followed. In 
the choice of games attention should be focused upon a few 
rather than many games. The recognized seasonal variations 
should be followed. There is a "top season," a "marble season," 

' (a) Dances of the People; (b) Folk Dances and Singing Games (G. Shirmer). 
2 The Folk Dance Book (A. S. Barnes & Co.). 



MUNICIPAL PLAYGROUNDS AND BATHS 209 

a "shinny season," a time for baseball, and another for foot- 
ball. The more individual competitive sports should be late 
in the afternoon, from 4.30 to 5.30. For boys under thir- 
teen, running, broad jumping, standing jumping, the hop, 
step, and jump, rope climbing, 50-yard dash, relay racing with 
a limit of 40 yards; for boys over thirteen and under fifteen, the 
running high jump, running broad jump, the running hop, step, 
and jump, rope climbing, the 75-yard dash, the 60-yard hurdle- 
race (hurdles 2 feet 6 inches), and relay racing hmited to 100- 
yards. For girls, basket-ball throwing for distance, corn-bag 
throwing for height and distance, and folk dancing in groups of 
sixteen or more are used. 

The American Playground Association has adopted a series 
of standard feats which every well-built boy should be able to do. 
A boy of twelve must pull up and chin a bar four times, clear 



.-"V^. 


■ Tr"- 


x^l^'^'N. 


1 ^ '> ?^ 


/> ''v7^ 


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'■./. ; 


>^',:-^'\. 


'■ ^/'' / 



First test. Second test. Third test. 

Fig. 126. — Form of badges designed by the author and adopted by Playground and 
Recreation Association of America, and which are awarded for tests of standard feats. 
(Copyright, 1912, by Playground and Recreation Association of America.) 

5 feet 9 inches in a standing broad jump, and run 60 yards in 
eight and three-fifths seconds. The second test for boys of 
thirteen consists of pulling up and chinning six times, a standing 
broad jump of 6 feet 6 inches, a 60-yard dash in eight seconds, 
or 100-yard dash in fourteen seconds. The third test for boys 
of fifteen increases the pull up to nine times, and introduces a 
running high jump of 4 feet 4 inches and a 220-yard dash in 
twenty-eight seconds. 

Badges are awarded for these three different classes, as shown in 
the illustration (Fig. 127) . They are supplied at a nominal figure. 

In this way the association encourages every boy to be proud 
of his physical efficiency, and the practice of these tests has dis- 
14 



2IO 



EXERCISE IN EDUCATION AND MEDICINE 



tinctly raised the average of physical efficiency in more than one 
community. 

From time to time exhibitions are given which may take the 
form of an athletic meet, circus, or pageant. Different wards 
of a city are brought into friendly rivalry by relay races from 
playground to playground, or combine for great mass drills or 
processions led by bands of music organized by themselves. 

A playground should be used for such national patriotic cele- 
brations as have been designed to replace the indiscriminate use of 




Fig. 127. — The swimming-pool at Sherwood Playground, Philadelphia. 



fireworks on the Fourth of July. The killed and injured at the 
Battle of Bunker Hill were only 1474 as compared with 1622 
killed and injured while celebrating the Fourth of July in 1909, 
and the organization of parades and pageants, such as those in 
Washington, Springfield, St. Louis, and St. Paul, might well be 
followed in other cities. 

The teaching of swimming should be part of the daily pro- 
gram, and such games as water polo or basket-ball as designed by 
Dr. A. E. Garland are much in vogue. Certain days should be 



MUNICIPAL PLAYGROUNDS AND BATHS 



211 



set apart for girls if they cannot have their own pool. Both the 
swimming- and wading pools can be systematically used for games 
of tag, leap frog, racing, and the like, and many children learn to 
swim instinctively or are taught by their companions. The sani- 




HR^T FLOOR PLAN 

Fig. 128. — Recreation building, Armour Square, Chicago, showing the only entrance 
to the pool from the dressing-rooms through the shower-room, where bathers can be 
inspected. 



tation of the swimming-pool is of the utmost importance, as it is 
always possible to spread contagious diseases by its indiscriminate 
use. Each child should take a soap-and-water bath before going 
in. The only entrance should be through the shower-bath room, 
and an attendant should stand at the door to inspect each bather. 



212 



EXERCISE IN EDUCATION AND MEDICINE 



Soap, towels, and trunks should be furnished and laundered, 
and the bather made to come out when shivering and blueness 
of the lips appear. The water should be changed as often as is 
feasible, and there should be a continuous stream rumiing in. 
The surface should be skimmed daily. If the water cannot 
be changed sufficiently often, the use of hypochlorid of hme will 
disinfect it. A cheese-cloth bag filled with the powder dragged 
through the pool until dissolved will destroy all bacteria, although 
this immunity works off in about forty-eight hours. The pro- 
portion used is 20 pounds to 1,000,000 gallons. 




Fig. 129. — Municipal swimming-pool and dressing-rooms, Brookline, Mass. 



In some communities public baths are the only provision 
made for exercise and hygiene, and the city of Brookline, Massa- 
chusetts, began its campaign for recreation and good health by 
building a municipal bath-house equipped with showers and 
swimming-pool. Free instruction was given to the residents 
of the town, and a smaller pool was constructed for the younger 
children. Closely following this bath-house a large g5annasium 
was built by the municipality, and organized instruction in 
gymnastics also free tc the residents was begun. Following this 



MUNICIPAL PLAYGROUNDS AND BATHS 213 

provision for outdoor play was made and a playground system 
was organized. 

Excursions may well form part of the playground activity 
of large cities. These may be undertaken once a week, and in 
this way walking trips to various points of historic interest may 
be made. A leader is appointed to take charge of the party, 
and a walk of from 3 to 5 miles is taken. Such excursions are 
popular in Rochester, Chicago, Buffalo, and Philadelphia, and 
are made the occasion for the study of botany and geology of 
the region, and a knowledge of plant life may thus be obtained 
by city children not possessed by their country-bred relations. 

On the playground the child Hves. In the school he only 
prepares to Hve. Watch how a child plays and you will know 
how he will work later on. That is why supervision by the 
director, who will cultivate all that is fair and honest and coura- 
geous in children, is an imperative necessity for every playground. 

It is the unsupervised playground that becomes a nuisance, 
where the bully holds sway and the worst accidents and injuries 
occur. Without supervision the stronger boys take possession 
of the equipment and give no opportunity to the smaller ones, 
and the whole value of these laboratories for character building 
is destroyed and their use perverted. 



CHAPTER XIII 

PHYSICAL EDUCATION IN SCHOOLS 

The school and playground must divide the responsibility for 
the child's normal growth and physical welfare with the home. 

The normal life of a child during its waking hours is one of 
constant muscular activity, but the teacher must inevitably sup- 
press much of this restlessness so fundamentally related to 
growth if discipline is to be maintained. The lessening of natural 
movements by school limitations during the years of growth is 
harmful, not only because muscular exercise is decreased, but 
because nervous tension and strain are more than correspond- 
ingly increased,^ and this tension should be repeatedly relaxed by 
periods of physical exercise designed with three objects in mind : 

First. — To counteract all evil tendencies of the school life 
itself, such as the effect of the school desk on the spine, the effect 
of inactivity upon the abdominal organs and generally bodily 
growth, and, lastly, the debilitating effects of indoor life. 

Second. — To give the neuromuscular training appropriate to 
his age, and to develop bodily control and the education of his 
growing powers by those simple exercises from which dances, 
gymnastic feats, and athletic sports and games are built. 

Third. — To provide facilities for the children to practice 
those natural and instinctive voluntary games and activities 
described in the last chapter, on which their normal growth of 
body, mind, and spirit depend. 

In the building of schools the sanitary engineer should see 
that every schoolroom has 15 square feet of floor space and 300 
cubic feet of air for each pupil, and a system of ventilation cap- 
able of supplying him with 30 cubic feet of pure air every minute. 
It is his duty to see that the window area is at least one-fifth 

IE. G. Brackett, P. E. Rev., vii, No. 3. 

214 



PHYSICAL EDUCATION IN SCHOOLS 



215 



of the floor space, and the light arranged to come from behind 
or over the left shoulder and not reflected directly from the 
paper on the desk into the eyes; that the desks are designed to 
fit not only the child of normal size for his grade, but also those 
who are abnormally large or small. C. L. Scudder, in his in- 
vestigation of school seating in Boston, found girls differing seven 
years in age and nearly 22 inches in height sitting at desks and 
seats of exactly the same size, and discovered gross misfitting 
of the desks in nearly every room he examined. In most schools 
there are still found seats so high that the pupil cannot touch 




Fig. 130. — Showing mechanism for adjustment of the Garber desk: lo, Adjustable 
top; 14, pivot of attachment for adjustable portion of top; 19, lever pressed up by fingers 
to overcome the spring 21 and release the rod 20 from the serrations 9, allowing the desk 
to be raised or lowered at will. 

the floor with his heels, desks of such height that the book is 
forced close to the eyes and myopia encouraged. Again, there 
are found desks so low that the round shoulders, the drooping 
heads, and the flat chests of their occupants are sadly noticeable. 

Tables showing variations in each school grade have been 
compiled from actual measurement by W. E. Stecher.^ They 
show that the desk may vary as much as 8 inches in one grade. 

The relation of the seat height to the desk height should be 
such as to permit the elbows to rest on the desk without stooping 
forward or unduly raising the shoulders, and the desk edge 

^ P. E. Review, October, 191 1, p. 457. 



2l6 EXERCISE IN EDUCATION AND MEDICINE 

should overlap the front edge of the seat. In a carefully ap- 
pointed schoolroom at least one row of seats and desks should 
be made adjustable in order to fit pupils that are not of the 
regular grade size. By this is avoided the unsuccessful and 
burdensome method of having all the school furniture made 
adjustable, which adds an additional weight to the teacher's 
already overloaded shoulders and is generally neglected. Most 
of the difficulty in seating pupils can be overcome by a self- 
adjusting desk and foot-rest Hke that invented by J. J. Garber, 



Fig. 131. — The Garber desk, adjustable by the pupil. 

of Philadelphia, which can be changed to fit by the pupil him- 
self with httle noise or loss of time, the two great objections to 
adjustable furniture (Figs. 130, 131). 

A perfect fitting seat and desk can guarantee only that the 
child shall be in the correct sitting position occasionally through- 
out the school day, for however well the desks may fit, pupils 
rapidly slump unless study periods are repeatedly interrupted 
by opportunities for movement and exercise. The upper part 
of the body leans forward upon or against the desk, constricting 



PHYSICAL EDUCATION IN SCHOOLS 



217 



the chest, crowding the abdominal organs, and impeding the 
venous circulation. The weight is supported by the arms, and 
the head, neck, and spine hang by the muscles of the shoulder- 
blades in abnormal curves. To relieve this overstrain of the 
back and shoulder muscles the pupil changes to a pose resting 
the entire weight of the trunk on the shoulder-blades and lower 
end of the spine (Fig. 132). The back sags down in a single long 
curve, the chest contracts, the breathing is impeded, and the 
circulation made sluggish. This position stretches the muscles 




Fig. 132. — Faulty posture (Shaw). 



and ligaments of the spine, rounds the back and shoulders, and 
shoves forward the chin. 

The correct sitting posture is one in which the pupil sits 
erect, the pelvis resting equally on the seat, with the arms beside 
the hips and the head poised so as to bring the center of gravity 
within a line joining the seat bones. This posture is economic 
on muscular energy and most conducive to correct carriage, 
but the demands of school life do not permit the pupil to keep 
it long. Reading, writing, and drawing are exercises that require 
deviations from the ideal, and if we add to these requirements ill- 



2l8 EXERCISE IN EDUCATION AND MEDICINE 

fitting desks and long periods of sitting, in which bad posture 
becomes habitual, the mischievous result cannot long be in 
doubt. 

The work of the school day should be arranged with these 
things in mind. 




Fig. 133. — Posture required to get support for the small of the back in the ordinary chair 
(American Posture League). 

The first year of the child's school life should not have 
more than one- third of the time in confinement at the desk 
(Shaw) . 

Short periods of sitting, followed by double that time spent 
in muscular activity out of the seat, should be the rule. This 
activity may in most cases consist of movements correlated with 
intellectual exercise. In the kindergarten the exercise is admir- 
ably combined with mental culture by the teaching of imitative 
games in which the large muscle groups are exercised in hopping, 



PHYSICAL EDUCATION IN SCHOOLS 



219 



jumping, and running, and in imitating with the arms the flight 
of birds and insects. The circulation is stimulated and postural 
faults are prevented, while at the same time the child is taught 
valuable lessons in natural history in which his interest never 
lags. The names of these games are suggestive of the action — 
"The windmill's fans around they go" (Blow), "Mow, mow the 



# 




Fig. 134. — Unsupported back while in the correct sitting position (American Posture 

League) . 



oats" (Hofer), "Little ball pass along" (Jenks and Walker). 
They may be divided into: 

1. Games of pursuit — "Chasing the squirrel." 

2. Imitation games — "Shall we show you how the farmer?" 
(Blow). 

3. Rhythmic and dancing games — "Tick-tack" (Hubbard). 

4. Marching games — "Left, left, Hsten to the music" (Gay- 
nor) . 



220 



EXERCISE IN EDUCATION AND MEDICINE 



5. Ball games — "In my hand a ball I hold" (Jenks and 
Walker). 

They are always accompanied by music, and most of them 
can be carried on to the primary schools. 

In the succeeding years of the elementary school the pro- 
portion of time spent at the desk may be gradually lengthened, 
but short periods of respite from sitting should be frequent and 




Fig- 135- — A kindergarten game in the school yard. 

devoted to brisk physical exercise. In the last year of the 
elementary school course there should be three stated periods of 
five minutes each during the morning and three during the 
afternoon session devoted to exercise corrective in character 
and designed to bring into use muscles inactive or overstrained 
at the desk. In addition to this, there should be a recess in both 
morning and afternoon session of not less than fifteen minutes 



PHYSICAL EDUCATION IN SCHOOLS 



221 



SO that the schoolroom may be thoroughly aired during recess. 
In this way, one-half hour morning and afternoon is spent in 




Fig. 136. — A recess game at the Thompson Street School, Philadelphia. 

exercise that is both corrective and recreational. All the pupils, 
if the weather and climate permit, should go out of doors and 




Fig. 137. — Method of using the school furniture to replace gymnastic apparatus in Phila- 
delphia schools. The "dip" between the seats. 



engage in spontaneous play, where they can run, shout, and give 
vent to their pent-up animal spirits, quicken their circulation, 



222 



EXERCISE IN EDUCATION AND MEDICINE 



and relieve the nervous tension caused by keeping still, and so 
rest and invigorate all their nervous and muscular system. 




Fig. 138. — "Follow your leader" through the seats and aisles of the schoolroom. 
The alternate files in the picture should be reversed, and the game continues until the 
players are back to their own desk. 

Special games have been designed and collected by Doctor E. 
H. Arnold, Jessie H. Bancroft, and William A. Stecher, in some 
cases original, in others, adapted from old and popular children's 




Fig. 139. — A roof playground in a crowded section of New York (Playground Associations 

of New York). 



plays, and changed for the use of the many children who have to 
occupy the confined space of the playground. These games 
should be taught and practised during the recess period, al- 



PHYSICAL EDUCATION IN SCHOOLS 



223 



though it is not so much the number of games that is necessary 
as their supervision, organization, and the time and space to 
play a few good ones. The classification of schoolroom and 
recess games has been carried to a high degree of perfection by 
H. Randall Worden, of Newark.^ 

The school day of children in the higher grades should have 
two five-minute periods of corrective exercise at least in addi- 
tion to the games of the recess above described. These exer- 
cises should be designed to promote quick, strong, muscular 








i 



te" 



Fig. 140. — Mosher's postures in standing. 



control; to expand and enlarge the chest by deep breathing; to 
bring the blood from the abdomen out into the extremities; to 
correct spinal deformities, and to teach the proper carriage of the 
body. 

It is not possible for a child to remain long at rest with the 
weight equally on both feet (Fig. 140, 2), because the tension on 
both legs being the same the muscles rapidly tire. The pupil 
instinctively rests his weight on the right, placing his left leg 

^ P. E. Review, June, 1911. 



224 



EXERCISE IN EDUCATION AND MEDICINE 



with bent knee out to the side as a prop (Fig. 140, i). This rest- 
ing position lowers the right shoulder, curves the spine, and may 
start the first stage of a permanent scoliosis. 

The best resting pose to teach is that recommended by 
Doctor EUza Mosher (Fig. 140, 3), in which the inactive foot 
is placed in front instead of at the side. In this the feet can be 
changed as the weight-bearing leg tires. 






INCORRECT POSTURE S 

le iK'ik diiij iniiik funii a i\s. 'H ''I'C I 



CORRECT POSTURE 

TI1C neck and Irurik form a slraij^lit. vcrl 



EXAGGERATED POSTURE 



Fig. 141. — Chart issued by the American Posture League. 



A series of three tests are described by Jessie H. Bancroft, of 
Brooklyn, to diagnose bad posture, and to apply the teaching of 
correct habits of standing and walking to large numbers of school 
children by the regular school teachers themselves. 

The triple test in use throughout the schools of New York 
has made it possible for even the untrained teacher to give an 
accurate estimate of a child's posture. The first part of the test 
is designed to find the pupil's ability to take the erect attitude. 
The long axis of the trunk should be in a perfectly vertical line 



PHYSICAL EDUCATION IN SCHOOLS 225 

and should continue the long axis of the head and neck. As seen 
from the side, the shoulder-blades should lie flat on the back 
and the middle of the round or the tip of the shoulder should 
He back of the forward border of the ear. To assist the eye of 
the observer, a vertical line may be dropped from the front of the 
ear to the forward part of the foot. In poor posture the axes of 
the head, neck, and trunk will form a zigzag instead of a straight 
line. This can be demonstrated by placing the extended hand 
on the shoulder vertically with the ulnar side down. 

Another simple way to estimate the extent of the deformity 
is to stand the patient beside an upright pole or rod. The 
variations from correct posture are three : the so-called fatigue, or 
gorilla type, in which the head is shoved forward, the chest sunken, 
and the abdomen protruded; the round hack posture, in which the 
hollow at the small of the back is obUterated, a posture cultivated 
by faults of seating already described; and the bantam, or pouter 
pigeon type, in which the chest is pushed forward and upward 
and the lower spine overextended, forming a marked exaggera- 
tion of the natural lumbar curve. This posture is always the 
result of faulty teaching, and is an exaggeration of the correct 
standing posture caused by the mistaken efforts on the part of 
the teacher to overcorrect the first two faults. 

The vertical line test, then, is the first element in standardiz- 
ing posture. A child who can assume a good posture for a few 
moments may not be able to hold it, so that some test of endur- 
ance is obviously necessary. The maintaining of good posture 
while marching is added as a second requirement, and following 
this the test of correct posture under exercise (Fig. 142) is added to 
complete the test. An entire class may be taken at once, or else 
they may be taken row by row. The standing pupils are looked 
over in profile. Those who do not stand in the correct position are 
asked to sit down or move to one side. Those who pass the first 
test move forward and form a single line across the front of the 
room, and are given marching exercises for four or five minutes. 
An effort is made during the march to distract their attention 
from any artificial effort for correct carriage by drilling them in 

IS 



226 



EXERCISE IN EDUCATION AND MEDICINE 



facings, marking time, halting, etc. As the march proceeds, old 
muscle habits reassert themselves and many pupils who could 
hold the correct posture for a few minutes fall back into habitual 
faults. Heads will drop forward, shoulders droop, and chest sink 
as they march. As these faults appear the child is taken out 
of the marching line. Those who pass the 
standing and marching tests are then put 
through the third test, designed to- show 
the action and endurance of the muscles 
of the spine and shoulders that are usually 
the first to yield to fatigue. When the 
arms are raised upward these postural 
muscles, if weak, allow the chin to come 
forward and the chest to sink backward, 
so that a few minutes spent in raising 
the arms forward and upward fully ex- 
tended, lowering them sideward and down- 
ward to the position at the start, will bring 
this weakness to the surface. 

Pupils showing the faults just mentioned 
should be dropped from the group. The 
sur\dvors of these three tests are put in 
Division i, and the remainder of the class 
in Division 2. This triple test should be 
given once a month, and should occupy 
from ten to twenty minutes in a class 
of forty or fifty pupils. Determining 
the posture is merely the first step, al- 
though a most important one, and the 
next is the systematic training of the muscular sense whereby 
a child may know whether or not he has corrected it, teach- 
ing him to assume it voluntarily, and the strengthening by 
exercise of those muscles whose weakness allows him to lapse.^ 




Fig. 142. — Correct pos- 
ture with forward arm 
raising. 



^ C. Ward Crampton's "elevation cues" are of great value to establish the correct 
standing posture. Thej^ are as follows: Head — up; chest — up; waist — flat; weight 
— forward (Syllabus on Physical Training, New York schools). 



PHYSICAL EDUCATION IN SCHOOLS 



227 



The fatigue posture is the most common, and this may be 
corrected in the class exercises by having the entire class 
stretch the arms strongly sideward at the shoulder level with 
palms turned downward. In this position the pupils sway for- 
ward as far as possible without losing the balance. Swaying 
forward and backward will almost always bring the chest for- 
ward into the correct position, although a considerable number 
of pupils require individual help in assuming it. When each 





Fig. 143. — Sunken chest position with 
weight on heels. 



Fig. 144. — Forward swaying with weight 
on the balls of the feet and correct chest 
position. 



pupil in a class has learned to stand correctly, a short drill or 
lesson to fix it in their minds together will be of service to fix it in 
their minds, together with certain home exercises described in 
detail in Miss Bancroft's^ book on the subject. 

This system has been in use for some time in the schools of 
New York, Newark, Detroit, and elsewhere, with most gratifying 
results. In a review of 33,000 Brooklyn children the first test 

^Jesse H. Bancroft, The Posture of School Children (McMillans, 1913). 



228 EXERCISE IN EDUCATION AND MEDICINE 

showed 43 per cent, who were unable to take the first standing 
position correctly. In the following June 83 per cent, of them 
passed the triple test in standing, marching, and gymnastic ex- 
ercise. The following year the methods were extended to up- 
ward of 200,000 children from the second to the eighth grades 
with commensurate results. 

This test standardizes posture and takes it away from the 
individual opinion of each teacher. It furnishes the basis for com- 
paring class with class. By putting the results on the blackboard 
the class has its percentage always before its eyes, the interest 
of the pupils is stimulated, and an incentive supplied that relieves 
the overconscientious teacher of the necessity for continual 
nagging. It is found by experience that about 85 per cent, of 
efficiency is the average figure, although some special classes 
have attained a percentage of 100. 

About 40 per cent, of high-school boys and girls require the 
correction of some postural defect. An analysis of 2000 consecu- 
tive examinations of children in one of the best high-schools in 
New York showed 32 per cent, of scoliosis with shght flat-foot, 
while in 12 per cent, the foot arches were badly broken down. 
In many cases the postural defects were merely a local symptom 
of a more profound constitutional weakness. 

Physical training in the schools is, however, not merely a 
matter of health. It is necessary for the education of the funda- 
mental nerve-centers of the body and the building of character. 
During the whole of childhood these centers are developing and 
their growth is not completed until adult life, as has been ex- 
plained in Chapter VI. For this reason not less than one hour in 
five should be devoted to training the motor area of the brain, 
in addition to the time allowed for free play. This should take 
the form of both gymnastics and athletics. 

Gymnastics, in addition to their corrective or medical char- 
acter, have a value in discipline and also in the accurate applica- 
tion of exercise for a given purpose; they are less dift'use than 
athletics, more concentrated, and for this reason they cannot 
be applied closely to the very young except in the guise of play. 



PHYSICAL EDUCATION IN SCHOOLS 229 

The schoolroom has been the battle-ground on which the 
Germans and Swedes have fought the most vigorous campaign 
in favor of their respective systems. Both have a place in the 
day's work. The more purely corrective exercises done to word 
of command and designed to prevent or remedy flat chest, round 
shoulders, and faulty standing positions stick more or less closely 
to the Swedish system, while rhythmic exercises done to music 
and the teaching of movements by imitation are more character- 
istic of the German system. 

The tendency in America is away from the Swedish day's 
order, in which movements are grouped according to the regions 
exercised, and toward the German idea which places emphasis 
on the object to be achieved. The day's order in the New York 
schools, designed by C. Ward Cramp ton, divides the period 
into five: (i) Introductory; (2) corrective; (3) educational; (4) 
hygienic; (5) recreative, in which rhythmic and static exercises 
are mingled. The strong German influence in St. Louis is seen 
in the physical training of her schools.^ 

In the Philadelphia schools recreation drills are used in 
addition to the more corrective work, and sometimes the children 
are allowed to run freely in the school yard, or to take jumping 
and vaulting exercises with the desks as apparatus. Rhythmic 
exercises to music or gymnastic games are also employed, but 
all gymnastic work in the schoolroom is short, light, and cor-' 
rective in character, and must stop short of perspiration. It is 
at best a makeshift, and should be looked upon as a substi- 
tute for the more vigorous exercise of the gymnasium or play- 
ground. 

Every school should be provided with a gymnasium large 
enough to allow vigorous work for an entire class or for several 
classes together, as in the Woodward School, in Cincinnati. 
Here the dressing-rooms and lockers for each sex permit a com- 
plete change of clothing with the liberal use of the shower and 
swimming-pool. 

The school gymnasium should be in a separate building if 

^ E. Kinderwater, P. E. Rev., vol. xv, 302. 



230 EXERCISE IN EDUCATION AND MEDICINE 

possible, as in the Berringer School at Newark, but when this is 
not feasible the upper floor should be used in preference to the 
basement. The ventilation should be abundant with forced draft, 
and the ceiling should be at least 20 feet high. A gallery contain- 
ing a running track should surround the room, and vaulting bars, 
ladders, and suspended parallels may be attached beneath to it. 
The vaulting horses, jumping standards, parallel and horizontal 
bars should be in groups from four to six as at West Point and 
in the University of Pennsylvania (see p. 260) and Lawrenceville 

I 




Fig. 145. — Dancing to the phonograph. Part of the regular physical training of the New 
York schools. (Dr. C. Ward Crampton, Director of Physical Training.) 

School gymnasiums to facilitate the handhng of large classes, 
and these should be set in floor sockets and easily removable 
so that the floor may be cleared for mass drifls, marching exer- 
cises, and games. Around the walls chest weights and other 
developing appliances should be set, with the boom, staU bars, 
dumb-befls, clubs, bar-bells, and wands. There should be an 
abundant supply of mats. The equipment will vary with the 
conditions, however, and a reliable gymnasium outfitter should 
be consulted for the design and instalment of the apparatus. 



PHYSICAL EDUCATION IN SCHOOLS 23 1 

The playground must provide 60 square feet of space for 
each pupil, or a plot 600 by 200 feet for a school of 1000 pupils, 
and the apparatus should be like that of a playground of the 
second class already described, except that there should be a 
strip of cement at least 25 feet wide adjoining the school house, 
and the rest of the ground should be built on a foundation of 
18 inches of cinders, rolled and top dressed with finely crushed 
stone, with 8-inch sand-pits under the horizontal bars and rings, 
and for jumping. 

The need for playgrounds about school buildings becomes 
more and more urgent as the population of a city increases, and 
in Philadelphia and New York the roof itself is used, caged in by 
wire netting. These roof playgrounds give the only opportunity 
many children have for engaging in outdoor games and athletics, 
especially in New York City where the population is so dense. 

Courses of instruction for teachers of physical education are 
given in the Summer Schools at Harvard, Pennsylvania, Wis- 
consin, McGill, and elsewhere, and many grade teachers add this 
to their other equipment and take charge of playground direc- 
tion during the summer vacation and during the winter, where 
they direct the voluntary exercises of pupils either in the gymna- 
sium or playground after school hours, usually without extra pay. 

The Public School Athletic League of the city of New York 
was founded in 1903 by Doctor Luther Halsey Gulick, then, 
superintendent of physical education. The organization was 
perfected by the election as officers of men influential in the 
political and financial world, and by securing the co-operation 
of teachers and principals. The first athletic meet was held at 
Madison Square Garden and brought about 1500 entries. Since 
then the league has given thousands of meets and often well 
over 600 athletic meetings in one year. At many of them over 
1000 competitors take part, and now a single school may hold a 
meeting with 700 competitors, the games covering all kinds of 
athletic competition. Running and relay racing constitute a 
majority of the events not only because of their value as exer- 
cise, but also because they enable a large number of boys to be 



232 



EXERCISE IN EDUCATION AND MEDICINE 



handled rapidly. Boys are classified by weight instead of age. 
The scales are set at the weight limit and competitors pass over 
them Uke sheep over a gate, each one being branded by a rubber 
stamp on the shoulder if he succeeds in standing on the platform 
of the scales without raising the bar. This is quick and con- 
clusive and prevents all possibility of discussion. There are con- 
tests also in high jumping, pole vaulting, putting the shot, 




Fig. 146. 



-Weighing competitors for the midget class before a race (the Public School 
Athletic League of New York) . 



basket-ball, soccer, football, cross-country running, swimming, 
ice and roller skating, and shooting. Baseball is perhaps the 
most popular, and hundreds of baseball teams compete against 
each other in the league. Trophies and medals have been 
secured for competition, and many other devices are used for 
extending the exercise to as many boys as possible. In order 
to minimize excessive competition, especially between individual 
boys for whom the strain and excitement might be too great. 



PHYSICAL EDUCATION IN SCHOOLS 233 

prize buttons were given to all boys who achieved a certain 
standard of merit. To win a button he must pass standards 
that have been set as follows : 

(A) For elementary school boys under thirteen years: 

1 . Run 60 yd. in eight and three-fifth seconds. 

2. Chin the bar four times. 

3. Standing broad jump, 5 ft. 9 in. 

(B) For all other elementary school hoys: 

1. Run 60 yd. indoors in eight seconds. 

2. loo-yd. dash outdoors, fourteen seconds. 

3. Chin bar six times. 

4. Standing broad jump, 6 ft. 6 in. 

(C) For high-school hoys: 

1. Run 220 yd. twenty-eight seconds. 

2. Chin bar nine times. 

3. Rimning high jump, 4 ft. 4 in. 

These tests have been extended to class competition, where all 
boys in the class compete to make an average. 

Teachers have been astonished as well as pleased with the 
improvement in discipline among these young and ambitious 
athletes, and this alone has insured their active co-operation as 
well as the enthusiastic support of the boys. The league aids in 
the maintenance of discipline by requiring a certificate from the 
principal stating that the boy has reached a passing mark in his 
studies and deportment before allowing him to compete either 
for a button or other prize. 

Systematic instruction in military rifle shooting has been 
made possible by the invention of the subtarget machine. It 
consists of a standard with an ordinary Krag military rifle 
attached to a mechanism on top. This is so adjusted that when 
aim is taken with the rifle at a target across the room and the 
trigger pulled the machine registers upon a miniature target the 
exact relative place that would have been hit if the gun were 
loaded, as well as the oscillation of the muzzle while aiming. As 
there is no danger connected with it the practice is rapid and 



234 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. 147. — Argument in favor of weight classes — the small boy is the older by three months 
(Handbook PubHc School Athletic League, New York) . 




Fig. 148. — Teaching New York school boys track athletics after school hours. In 
125 school centers the attendance for one month (June) was 2,043,973 boys. (Dr. C. 
Ward Crampton, Director of Physical Training.) 



PHYSICAL EDUCATION IN SCHOOLS 



235 



economical, the mechanism being easily set up in any school 
room. The instructor standing at the boy's side is able to follow 
the manner in which he is aiming and to correct his defects. In- 
struction in the holding and sighting of the rifle is given and 
annual interschool contests are held, ending in a final contest 
among the winning schools at Creedmoor with the actual rifle 




Fig. 149.- 



-Subtarget gun machine for rifle practice in high schools (Handbook of Public 
School Athletic League, New York). 



at distances of 100 to 400 yards. The boys thus have an oppor- 
tunity for acquiring the knowledge of wind, atmosphere, and 
light necessary for good shooting in the field. This has been 
made part of the program for the School Athletic League and 
has been a source of keen interest to the boys, many of whom 
have acquired great skill. Upon attaining a certain degree of 



236 



EXERCISE IN EDUCATION AND MEDICINE 



efficiency each competitor is given a badge. The national im- 
portance of having an army of boys graduated every year, each 
one knowing the feel of a rifle in his hand and having a knowl- 
edge of its use, a knowledge that never leaves him, need not be 
dwelt upon here. 

The PubUc School Athletic League has extended its work by 
the formation of the girl's branch. Voluntary classes in, gym- 
nastics, games, and dancing have been introduced among the 
girls attending the pubUc schools, from which teachers are by no 
means excluded, and many of them attend, leading classes of 




Fig. 150.- 



-The English ribbon dance (PubHc School Athletic League, New York). (Amer- 
ican Sports Pub. Co.) 



their own. Exercises most popular and generally practised by 
the girls are the peasant dances of Sweden, Scotland, Ireland, and 
Spain, involving much gymnastic work, and developing strength, 
agility, and grace. Games adapted for indoor and outdoor spaces 
are practised, and relay races between classes and schools have 
become a favorite feature. Athletic competition in public be- 
tween girls or teams of girls has been discouraged, and its place 
taken by dancing fetes in Central Park that have become so 
attractive a sight. 

Owing to the difficulty of finding a spacious ground for 



PHYSICAL EDUCATION IN SCHOOLS 



237 




Fig. 151. — Relay race, Girls' Branch Public Schools Athletic League. 




Fig. 152. — Field day for school children, Franklin Field, Philadelphia, June 20, igo8 (Play- 
grounds Association of Philadelphia) . 



their athletic competitions and exhibitions, the Pubhc School 
Athletic League has been the means of drawing attention to the 
need of good playgrounds in New York City. Largely through 



2;8 



EXERCISE IN EDUCATION AND MEDICINE 



the influence of its officers, $500,000 was appropriated by the 
city for the purchasing and equipping of four athletic fields. 




It was impossible to procure sites on Manhattan Island, so that 
one was built in Astoria, one at Crotona Park, another at Staple- 
ton, Staten Island, and a fourth in south Brooklyn. 



PHYSICAL EDUCATION IN SCHOOLS 239 

These fields are equipped with running tracks, grand stands, 
and dressing-rooms, but if adequate provision had been made 
as the city was built it would not have been necessary to go so 
far afield. 

Leagues similar in objects and character have since then 
been formed in Newark, Chicago, Cleveland, and elsewhere. In 
Newark, where the work is particularly active and well organ- 
ized, a medical examination of all contestants is required, about 
80 boys out of 2000 competitors being found physically unfit. 
In Philadelphia an athletic committee of the Playground Asso- 
ciation organized the athletic interests of the schools, both 
public and parochial, on rather different hues, both sexes being 
included in one league, and the first field day was held in June, 
1908, with 5000 children of both sexes taking part. A yearly 
festival has been given ever since on Belmont plateau. It differs 
from the leagues of New York, Newark, and Cleveland by laying 
more stress on exhibition drills and interschool competition in 
drills and games, after the German custom, where as many as 
400 pupils from one school take part in a drill in competition 
with groups of 50 to 100 from smaller ones. In addition to 
this there are group contests, relay races, and individual events. 
By such means the play life of the child can be provided for in 
addition to the more purely literary exercises that come more 
obviously into the province of the schools. 



CHAPTER XIV 

PHYSICAL EDUCATION IN COLLEGES AND 
UNIVERSITIES 

There is a distinct break between school life and the life of 
the student. 

Most school children go into business or into a trade on 
leaving school, and many men enter college who have had but 
meager experience of school life. The long hours of school work, 
the nervous exhaustion of teaching, the nights spent in study, 
and the days in the office, factory, or shop, all leave their im- 
print so deeply that the knowledge, or even the desire, for a fuller 
and larger physical Hfe may be atrophied or stamped out in the 
very youths whose success in after-life vitally depends on the 
development and conservation of their physical powers. 

The college student must then be educated in personal 
hygiene. His remediable defects must be corrected and his 
physical powers trained to the highest point of efficiency. He 
must be taught that graceful carriage characteristic of the well- 
bred man. His powers of self-preservation and efficiency must 
be increased. If he has not learned it already, he must be given 
the capacity for physical recreation by knowledge of sports and 
games, for athletic activity should be the safety valve of a 
sedentary life, and should also teach those social and moral 
qualities which can be cultivated so well in no other way. 

The necessity for physical training to go hand in hand with 
the other courses of the college curriculum has been recognized 
by advanced thinkers from the earhest times. Benjamin Frank- 
lin, in writing the pamphlet in 1749 that led to the founding of 
an academy for the education of the youth, now the University 
of Pennsylvania, expressly states "that to keep them in health and 
to strengthen and render active their bodies they he frequently exer- 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 24I 

cised in running, leaping, wrestling, and swimming." Nearly 
forty years later Thomas Jefferson wrote to Peter Carr con- 
cerning his studies: 

"Give about two hours of every day to exercise, for health 
must not be sacrificed to learning." 

In drafting the plans for the University of Virginia Jefferson 
did not forget the place of exercise, but advocated mihtary drill 
and maneuvers as the best means of exercise to meet conditions 
then existing. 

The wave of interest in German gymnastics reached America 
about 1825, as already described in a previous chapter, and the 
catalogue of Harvard College (182 7- 182 8) contains the name of 
Dr. Charles FoUen, superintendent of the gymnasium and in- 
structor in German. About this time these exercises were intro- 
duced into Brown, Williams, and Yale, as well as many secondary 
schools, but the German pioneers soon found that their status in 
America was not considered equal to the teachers of more purely 
intellectual subjects, and soon tired of teaching boys to turn 
somersaults when the rewards for more purely intellectual work 
were greater. 

In i860 the first chair of Physical Education and Hygiene 
in an American college was established at Amherst. Its oc- 
cupant. Dr. Hooker, was succeeded within a year by Dr. Ed- 
ward H. Hitchcock, who retained the professorship until his 
death in 19 11. His collection of vital statistics are the longest' 
continuous series of observations on college men yet made, 
and the conclusions from them, embodied in charts and reports 
compiled by him and his successor, Dr. Paul C. Philips, show 
a consistent improvement in the students' health and propor- 
tions from freshman to senior year under systematic exercise. 
From them we have been able to conclude that the height and 
weight of the Amherst student at least has gradually increased 
during the last fifty years. 

In 1879 Dr. Dudley A. Sargent was given the direction of 
the Hemenway Gymnasium at Harvard, and he at once began 
the patient accumulation of vital statistics now reduced to chart 
16 



242 



EXERCISE IN EDUCATION AND MEDICINE 



&1 



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244 EXERCISE IN EDUCATION AND MEDICINE 

form and available for reference. Owing to the extreme develop- 
ment of the elective system at Harvard no requirement for 
physical exercise was made, all work being voluntary and car- 
ried out according to Dr. Sargent's system of individual exer- 
cises in contrast with the usual class instruction. 

In the last ten years there has been a marked development 
in the attention paid to physical training in American colleges. 
The Division of Physical Education and Athletics in the Uni- 
versity of Chicago was founded in 1892, and by the construction 
of the Bartlett Gymnasium in 1904 it became possible to carry 
out a definite undergraduate requirement, and also to provide 
for the adequate supervision and control, financial and other- 
wise, of university athletics. This is the ideal relationship be- 
tween gymnastic training and competitive athletics, each having 
its place in a complete system of physical education. 

The Department of Physical Education, reorganized in 1904 
at the University of Pennsylvania, requires from the four under- 
graduate years and from the primary years in the professional 
schools, except those holding a bachelor's degree, a minimum of 
two hours of exercise a week. 

The Department of Hygiene in the College of the City of 
New York, organized in 1906, has a two-year requirement and 
rigorous system of examination and health supervision, while 
the Department of Hygiene and Physical Education at Princeton, 
founded in 19 10, has begun with a freshman requirement of 
three periods a week. 

In 19 1 2, 94 per cent, of the colleges on the Carnegie Founda- 
tion had estabhshed definite instruction in physical training, 
while 75 per cent, of the officers in charge were members of the 
college faculty. Regular exercise is prescribed for the whole 
four years in some cases or, more frequently, for the first two 
years only, and one-half of them have provision for the care of 
the physically defective. Definite scholastic credit is given in 
over 50 per cent, of all these colleges.^ 

1 Meylan, "Status of Physical Education in American Colleges," P. E. Rev., 
February, 191 2. 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 245 

A university course in physical education should begin with 
a careful examination to find the exact bodily condition of the 
student, and so to give an intelligent foundation on which to 
base advice and instruction. The student should be measured 
and his strength tested to see how he compares with his fellows 
in proportion and power. His posture and muscular develop- 
ment should be noted and his heart, and lungs examined for any 
latent weakness or disease. The acuteness of his sight and hear- 
ing should be carefully calculated, for he must know if there be 
any serious obstruction of the two most important avenues by 




Fig. 156. — Exercise to develop the abdominal muscles on the Swedish stall bars (Uni- 
versity of Pennsylvania gymnasium). 



which his knowledge is to come to him. At the College of the 
City of New York, Dr. Thomas A. Storey lays stress on the 
medical examination and the examination of the teeth, while 
the examination of the nose and throat is conducted as a routine 
measure at Haverford and at Michigan.^ 

The examination of the student is not complete without a 
test of his ability to accompHsh certain muscular feats that 
cover the main activities of the body, both in exercises of maxi- 
mum effort and of endurance. 

^ George E. May, M. D., "Results of One Thousand Examinations of the Nose 
and Throat at University of Michigan," P. E. Rev., vol. xiv. 



246 EXERCISE IN EDUCATION AND MEDICINE 

An analysis of the examination of 1000 freshmen at the Uni- 
versity of Pennsylvania showed that about 30 per cent, had 
Hved a sedentary Hfe, and it is all too common to find the 
broken-down arch of the foot, the fiat chest, and protruding 
abdomen of the anemic school boy, with his round shoulders, 
protruding chin, and flabby muscles, the drooping shoulder 
and the curved spine, or the dull hearing and faulty sight 
that have been the unsuspected cause of headaches, nervous 
irritabihty, and exhaustion. It is the province of the Depart- 
ment of Physical Education to bring this defective physique 
up to its normal level. For specific defects corrective exercises 
are required. Recently, a young man came to college having 
been rejected at West Point because of fla;t-foot and lateral 
curvature. A six months' course of prescribed exercise, lasting 
about one-half hour daily and carried out faithfully, enabled 
him to pass the required physical examination easily. 

Another freshman, entering on the study of architecture, 
complained that he could not study on account of frequent 
headaches, especially after reading or drafting. His eye ex- 
amination showed less than one-half the normal acuity, unsus- 
pected and, of course, uncorrected by glasses. 

A third-year man reported a progressive loss in weight, with 
distinct signs of incipient tuberculosis in the apex of one lung. 
A course of forced feeding, rest, and other treatment enabled him 
to regain his lost weight and to overcome the disease in a month 
or two, whereas if left to himself he would have broken down 
during the course of the winter's work. 

Hundreds of similar cases come under the medical examiner's 
eye each year, and proper advice at the beginning of his course 
will prevent the appalling waste of time and energy inevitable 
for the man who struggles along with these handicaps uncor- 
rected. Constant personal counsel about exercise and other 
questions of personal hygiene go far to safeguard the comfort 
and efficiency of these students. The main work of the director 
must, however, be devoted to the average man coming from the 
farm, office, factory, shop, or school with no athletic ambitions, 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 247 

but wanting to make every moment of his time count. The 
college must provide him with faciUties for exercise of the right 
sort to put him and keep him at the highest level of physical 
efficiency, without involving too great an inroad upon his 
limited time. 

A course of exercise of progressing difficulty should be care- 
fully designed and graded for the average man, who is neither 
subnormal like the defective nor supernormal hke the athlete, 
who has neither the desire nor the abihty to represent his uni- 
versity on the track or field, but who wishes to be at his highest 
point of physical vigor throughout his college course. A fixed 
requirement is essential with credit on the basis of laboratory 
work, because a course of exercise requires guidance quite as. 
much as the other subjects of the college curriculum. The 
student's attitude will be antagonistic to required work of any 
kind, unless credit be given for the time taken from those studies 
which he thinks have a more direct bearing on his life-work. 

Two objects must be kept in view in planning such a course: 

First. — The correction of those bad physical habits that come 
with the student's sedentary life. 

Second. — The systematic education of those bodily powers 
that will be most useful to him during his college Hfe and after 
graduation. 

The sudden change from the active outdoor life of the 
country-bred boy to the confinement of college work is not 
unattended with dangers to health, as shown by the tendency 
to constipation and other disturbances of digestion, headaches, 
and other common ills for which the college medical examiner is 
continually consulted. The long hours spent in the lecture rooms, 
not always too well ventilated, or bent over the laboratory table, 
must also be corrected by exercises that will strengthen the tired 
back and stimulate the sluggish heart and inactive digestion, 
that will draw the blood from the tired brain and congested 
abdominal organs into the pulsating muscles and expanded lungs, 
and, at the same time, it should give a real education to his 
physical powers. A successful course must develop those racially 



248 EXERCISE IN EDUCATION AND MEDICINE 

old co-ordinations that have given man his supremacy over 
brute creation, and civilized man his superiority over the savage, 
for, contrary to popular opinion, the civilized nations are as 
dominant physically as they are intellectually. 

It is by the cultivation of the great fundamental and vital ac- 
tivities that civilized man has asserted and maintained his superi- 
ority over more primitive races, and the rehearsal of these activi- 
ties must form the basis for a course in physical education if it is to 
be interesting to the student and sound from the standpoint of the 
pedagogue. These are the exercises of locomotion, like running, 
jumping, swimming, and climbing; of fighting, throwing, dodg- 
ing, catching, striking, and wrestling; of co-operation under a 
leader in group games where men are organized in a team, 
individual excellence being sacrificed to the common good. 

The cultivation of physical intelligence can never lose its 
value, no matter how artificial may be the conditions of the com- 
munity in which one lives. It is what teaches a man to escape 
injury in the many emergencies of daily life. It saves what 
would be a broken arm or a sprained wrist in one who has not 
learned to keep his feet on the sHppery pavement or who cannot 
fall without hurting himself, while many costly Hves are lost 
annually through inability to swim, jump, climb, or dodge. 
These fundamental actions of locomotion and fighting form 
the basis of all games that have survived to the present time, 
and are more fully described in the chapters on athletics and 
age, sex, and occupation. 

Exercise for the college must be put in such form as to get 
the greatest possible result from the time expended. Games must 
often be modified and intensified to fit the conditions of college 
life. It takes a field 100 by 60 yards to accommodate 22 men 
in football, 24 in lacrosse, or 18 in baseball, but 1000 men can 
be exercised in the same space in similar movements by modify- 
ing them for class work, and the course thus made progressive 
and logical from the teaching standpoint. 

In the illustration (Fig. 157) a class of nearly 500 students 
is seen engaged in athletic exercise on Franklin Field, University 




249 



250 



EXERCISE IN EDUCATION AND MEDICINE 




PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 25 1 

of Pennsylvania. Each man in turn sprints 30 yards, clears a 
hurdle, takes a standing broad jump, a running high jump, and 
puts the 12-pound shot, a short pause taking place between 
each act. The signal is given by a whistle, and at each signal 
nearly loo men perform one of these various feats in groups. 

At smaller colleges, especially those surrounded by fields, 
the problem of providing athletic instruction for all the students 
is not so difficult. At Amherst, where sports are part of the 
regular work, the men are organized into groups by fraternities 




-Freshmen playing hockey as part of the course of required exercise at the 
University of Wisconsin. (Courtesy of George W. Ehler.) 

and departments, and a series of progressive tournaments are 
carried on in football, baseball, basket-ball, and tennis, each 
team playing the other, and in this way every man is provided 
for and required to take definite training in sports and games. 

Plans have been put in operation at various colleges to make 
the athletic work progressive, and so comparable with the rest 
of the college work. 

At Pennsylvania a wide range of election is allowed to men, 
especially in their two final years, but a student choosing track 
athletics has definite instruction in the technic of running, jump- 
ing, and throwing weights. To enter, he must pass the test in 
one track and two field events, making a total of more than 60 
per cent., according to the table given on page 252. 



252 



EXERCISE IN EDUCATION AND MEDICINE 



PERCENTAGE SCALE FOR TRACK ATHLETES 

Percentage rating. 30 per cent. 40 per cent. 50 per cent. 60 per cent. 

100 yards 1 2.1 sec. 12. sec. 11. 4 sec. 1 1.3 sec. 

220 yards 26.4 sec. 26.2 sec. 26 sec. 25.3 sec. 

440 yards 71 sec. 69 sec. 67 sec. 65 sec. 

880 yards 2 min. 45 sec. 2 min. 40 sec. 2 min. 35 sec. 2 min. 30 sec. 

I mile 6 min. 30 sec. 6 min. 20 sec. 6 min. 10 sec. 6 min. 

120 hurdles 20 min. 30 sec. 20 min. i sec. 19 min. 4 sec. 19 min. 2 sec. 

High jump 3 ft. 9 in. 3 ft. 11 in. 4 ft. 2 in. 4 ft. 4 iii. 

Broad jump 12 ft. 6 in. 13 ft. 4 in. 14 ft. 2 in. 15 ft. 

Pole vault 6 ft. 3 in. 6 ft. 8 in. 7 ft. i in. 7 ft. 6 in. 

Shot put 24 ft. 25 ft. 26 ft. 27 ft. 

i6-lb. hammer. . . 55 ft. 60 ft. 65 ft. 70 ft. 

Percentage rating. 70 per cent. 80 per cent. 90 per cent. 100 per cent. 

100 yards 11. 2 sec. 11. i sec. 11 sec. 10.4 sec. 

220 yards 25.1 sec. 24.4 sec. 24.2 sec. 24 sec. 

440 yards 63 sec. 61 sec. 59 sec. 57 sec. 

880 yards 2 min. 25 sec. 2 min. 20 sec. 2 min. 15 sec. 2 min. 10 sec. 

I mile 5 min. 50 sec. 5 min. 40 sec. 5 min. 30 sec. 5 min. 20 sec. 

120 hurdles 19 sec. 18.4 sec. 18. i sec. 17.4 sec. 

High jump 4 ft. 7 in. 4 ft. 9 in. 5 ft. 5 ft. 2 in. 

Broad jump 15 ft. 10 in. 16 ft. 8 in. 17 ft. 6 in. 18 ft. 4 in. 

Pole vault 7 ft. II in. 8 ft. 4 in. 8 ft. 9 in. 9 ft. 2 in. 

Shot put 28 ft. 29 ft. 30 ft. 32 ft. 

i6-lb. hammer. . . 75 ft. 80 ft. 85 ft. 90 ft. 



At the end of his year he must pass in two track and three 
field events or three track and two field events, his grading being 
marked according to the results of this examination. 

The same method of teaching should be employed in swim- 
ming, a most important exercise, which has as yet been made 
part of the required work of only about fifteen American col- 
leges. Here the requirement varies from the ability to swim 
100 feet up to the abihty to swim 200 yards, knowledge of the 
various strokes, with instruction in the most improved methods 
of life-saving, breaking the holds that would be taken by a 
drowning man in the water, and resuscitation of the apparently 
drowned by the Schaeffer method. 

Examination should be made of the swimmer's knowledge 
and versatility rather than of his speed only. 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 253 




Fig. 160. — ^The march past of the swimming squad (Athletic Pageant, University of Penn- 
sylvania, 1913). 




Fig. 161. — ^The building of pyramids as a class exercise (University of Pennsylvania 

gymnasium). 



254 EXERCISE IN EDUCATION AND MEDICINE 

The following scale is designed for those who elect swimming 

at Pennsylvania: 

SWIMMING 

Entrance examination Swim loo feet any style. 

To enter second year. , Swim (a) loo yards any style. 

(b) loo feet on back. 

(c) Dive from springboard or floor. 

(d) Tread water or float, using hands 

only. 
To enter third year Swim (a) Breast stroke, 200 yards. 

(b) Overarm single, 150 yards. 

(c) Swimming on back, arms, and legs. 

(d) Dive from springboard or 6-foot 

platform. 
To enter fourth year Swim (a) Trudgeon stroke, 100 yards. 

(b) On back, legs only, arms only, 

sculHng 50 yards. 

(c) Swim under water, 30 feet. 

(d) Dive from lo-foot platform. 
Final examination Swim (a) Crawl stroke, 100 yards. 

(b) Pick up two objects in 8 feet water. 

(c) Tow a man 50 feet. 

(d) Break four holds in the water. 

(e) Shaeffer's method of respiration. 
(/) Dive, front and back, each. 

(g) Smm 440 yards any style. 

For those whose exercise should not be more active than 
walking a series of excursions of increasing length is arranged, 
taking in the various points of interest in the neighborhood, a 
short walk on Wednesday, and a longer walk on Saturday, 
throughout the second college term. 

The exercises of the gymnasium are more purely gymnastic 
and educational in character, and can be more closely designed 
for their purpose. Class work should be made progressive in 
difficulty, each movement leading to the next. In teaching a 
movement like rope climbing the student should be first ex- 
amined and marked as to his ability to climb a rope by his arms. 
If he cannot do so at all (usually 40 per cent.), he should begin 
by pulling his weight up by both arms and dropping to the 
floor. He should then learn to jump and catch the rope, pulling 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 255 

his weight up several times, afterward learning to catch the 
rope with the arms and legs and climb by the use of both, and 




Fig. 162. — Indoor practice for crew candidates during the winter. Rowing tank, Uni- 
versity of Syracuse. The water is circulated by propellors as well as by the oars. 

SO on, until he is able to climb with ease by using the arms and 
legs or the arms alone, to carry the rope up with him, to tie a 




Fig. 163. — A class drill in free movements and elementary dancing steps (University of 
Pennsylvania gymnasium). 

loop in which he may rest, or to descend with one arm disabled, 
or carrying a bundle. He is then re-examined and passed in that 
method of locomotion. 



256 



EXERCISE IN EDUCATION AND MEDICINE 



Fencing is part of the regular class work at West Point, 
and boxing can be analyzed for class purposes and taught as a 
class drill. The positions of defense, leads, and guards, first 
simple and then complex, with and without foot work, until a 
fairly good knowledge of this method of defense is obtained. 




Fig. 164. — Holding by the legs and one hand in rope climbing 



The rudiments of wrestHng should also be taught in the 
form of a gymnastic drill, and g3nninastic games should be freely 
used to train every man to know his powers and limitations in 
all the activities of running, leaping, climbing, and dodging, 
while no course would be complete that failed to recognize the edu- 
cational value — physical, mental, and ethical — of those athletic 
sports that cultivate courage, pluck, and tenacity of purpose. 
Where possible all such exercises should be conducted in the 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 



257 



open air, or failing that, in a spacious well-ventilated and well- 
lighted gymnasium. The college gymnasium should be pro- 




Fig. 165. — Class work in fencing in the gymnasium at West Point, Captain Koehler 

director. 

vided with several exercise rooms to accommodate the many 
activities that would otherwise clash, the best and most popular 
hours being the late afternoon. Where this is not possible, much 




Fig. 166. — Wrestling used as a class exercise (University of Pennsylvania gymnasium): 

The chancery hold. 

may be done by the use of nets dividing a large hall into separate 
courts for basket-ball, wrestling, gymnastics, and other games, 
and permitting the entire floor to be supervised by one man. 
17 



258 



EXERCISE IN EDUCATION AND MEDICINE 



Separate rooms are necessary for fencing and boxing, and 
for indoor practice by the crew, hockey team, baseball teams, 
etc., while corrective exercises are better done apart from the 
noise and confusion of the main exercise hall with its constant 
succession of classes. 

Each building should be provided with a pool at least 60 feet 
in length and 25 feet in width, although 100 by 30 feet is better. 
The water should be frequently changed, and from time to time 




Fig. 167. — Gymnasium floor divided into three courts by nets, thus permitting basket- 
ball in the central court and wrestling and gymnastics at the two ends. This allows of super- 
vision of the whole floor by one man (University of Pennsylvania). 



bacterial counts should be made and care exercised in avoiding 
the possibility of infection. ^ 

In the practical management of classes the multiplication of 
the apparatus in sets of six or ten is valuable. The largest class 
may thus be divided so as to prevent the waste of time that 
occurs when a long line of men must wait their turn to perform 
their exercise on a single horse or pair of parallels. 

1 Ravenal and Lyster, "Disinfection of Swimming Pools," American Medical 
Association Journal. 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 259 

A year's course of exercise will of necessity vary consider- 
ably with the special conditions to be found in each college 
or university, but the following plan, which is in use at the 
University of Pennsylvania, will be found to contain the main 
essentials of progression : 

October: Physical examinations. Examination of the eyes, instruction in 
swimming to first-year men, prescription and demonstration of special exercises for 
round or imeven shoulders, constipation, flat-foot, weakness of abdominal walls, 
etc., athletic examination given by instructors on the gymnasium floor. 

November: Class work in the gymnasium. Marching tactics, quick time and 
double time, free setting-up exercises, and gymnastic games. 

December and January: Examination and first arrangement of apparatus. 
Low horizontals, climbing ropes, flying rings, and vaulting horse. Men are graded 
as a result of this examination into first, second, third, or leaders, and fourth {gym- 
nastic team) grades. 

February: Examination and regrading for second arrangement of apparatus. 
High horizontal bar, tumbling, buck, long horse and parallel bars, class drill with 
wooden wands or Indian clubs. 

March: Third arrangement of apparatus. Pyramids, boxing or wrestling 
drill, iron dumb-bells, steel wands, dancing steps, and gymnastic games. 

April: Free drill, gymnastic games, and athletic sports, outdoors when pos- 
sible. 

May: Physical examination of graduating class. 

Such a game as dodge ball is peculiarly adapted to a class 
of small or large numbers when played out of doors in spring. 
The start in sprinting, hurdhng, broad and high jumping, putting, 
the shot, dancing steps, are here introduced, as well as progressive 
tournaments in baseball and tennis. 

In some gymnasia, such as Northwestern University and 
University of Wisconsin, provision is made for the practice of 
outdoor athletic sports under cover. At Dartmouth there are 
three running tracks, with 120-yard straightaway, one circular 
track, six and two-thirds laps to the mile, a full size baseball 
diamond, and provision for field athletics, under the same roof 
as the gymnasium, enabling students to take any form of gym- 
nastic or athletic exercise independent of weather conditions. 

At Toronto University the Department of Physical Educa- 
tion has been associated under the same roof as the Young Men's 



26o 



EXERCISE IN EDUCATION AND MEDICINE 



Christian Association and the various student clubs, Hterary, 
social, and athletic. This combination cannot but lower the 
position held by physical education in the college curriculum, 
divorcing it in the minds of the student from its educational 
place and making it merely a part of the other voluntary social 
activities of student life. 




Fig. i68. — Gymnasium floor, showing apparatus in place for class work. Beginning 
with the background they are horizontal bars, flying rings, climbing ropes, and parallel 
bars arranged in gangs of six. The parallel bars are placed in floor sockets and can be 
replaced by the buck or long side horse (University of Pennsylvania). 



The year's work at Pennsylvania usually concludes with an 
outdoor exhibition of the united classes. This may take the form 
of an athletic pageant, such as the one held in 1913, in which 
all the classes and athletic teams of the university, after parading 
in their characteristic uniforms, gave an exhibition covering the 
entire range of gymnastic and athletic sports. 

It is found that after two or three years of the regular educa- 
tional classes men drift into specialties, and devote themselves 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 261 




to advanced boxing, wrestling, fencing, and swimming, or join 
the crew, football, or baseball squads. A high standard of 



262 EXERCISE IN EDUCATION AND MEDICINE 

excellence is required to qualify in most of these specialties; 

many try for a team and, failing, drop back into the class work. 

The following table shows the distribution of men in the 

different sports and games at Pennsylvania during the year 19 13: 

Reporting. Retained. 

Baseball 130 81 

Basket-ball 94 24 

Boxing 40 25 - 

Crew 203 31 

Fencing 44 14 

Football 150 87 

Golf 20 16 

Gj'mnastic team 18 9 

Soccer 45 20 

Swimming 97 37 

Track 297 94 

Wrestling 89 24 

Lacrosse 34 26 

Rifle 15 7 

Mask and Wig Dancing Chorus 62 62 

Total number in athletics, etc 1338 557 

Number of men in g3Timastics 1282 

Number of men taking corrective exercises 400 

Of the 1338 candidates for various teams, only 557 were 
retained. Those who are not retained on a squad return to the 
class work in gymnastics or athletics. 

The men who have the physique and constitution necessary 
to become intercollegiate athletes, as shown by the 557 retained 
on the varsity squads, number less than 10 per cent, of the total 
enrolment of the college, for the severity of competition in inter- 
collegiate athletics and the high standard of merit required for 
success separates them almost into a special class. The average 
weight of a football player on a college team is about 174 pounds, 
35 pounds more than the average man. The oarsman weighs 
about 164 pounds, or 25 pounds more than the ordinary student, 
whose height he also exceeds by about 3 inches. The light 
routine exercise suitable for the average student is not enough 
for them, and facilities should be given them for practising their 
chosen specialties, but the necessity for advice and direction, 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 263 

and, in some cases, restriction, has time and again been tragically 
shown. 

The actual conduct of competitive intercollegiate athletics 
may, to a great extent, be left in the hands of the students 
themselves as part of their social training, if the final court of 
appeal be a representative committee chosen from both faculty 
and students. The university should, however, require two 
things before allowing a student to enter his name on an athletic 
squad : 

First — A careful examination of his physical condition. 

Second — A rigid standard of scholarship for every man who 
may represent the institution in an intercollegiate contest. 

Nearly 10 per cent, of all candidates for athletic honors are 
prevented by the preliminary medical examination from en- 
dangering health or life in violent competition, and this alone 
shows the value of such a precaution wherever the more strenu- 
ous forms of athletics are practised. 

Students frequently present themselves as candidates for 
teams who have unsuspected organic lesions of the heart, danger- 
ous hernias, or incipient tuberculosis — men who have no place 
in the exhausting struggle of a game like football, or a boat 
race, or a half-mile run, but for whom regular judicious Hght 
exercise would have the greatest value. 

The medical examiner should, of course, have complete 
authority to decide on the best course to pursue in each case, 
and he will usually find with added experience that he may 
permit many a man to engage in vigorous sports with advantage 
to his health whose condition would be condemned by one who 
went entirely by the standard text-books. This question is more 
fully discussed in the chapters on Physiology and Disorders of 
the Circulation. 

The university may undertake the supervision of the diet of 
all men in training, even to the extent of establishing a training 
table, although it is too often considered a special privilege by 
the athlete who, supposed to pay the full board, frequently pays 
little or nothing. 



264 



EXERCISE IN EDUCATION AND MEDICINE 



The question of scholastic and amateur standing is scarcely 
within the scope of this chapter, but some colleges and universi- 
ties require even a higher standard among their athletes than 
from the general student body, and the tendency in most aca- 
demic councils is toward greater stringency in the requirements 
and more rigid enforcement of the regulations. The worst 
abuses of intercollegiate athletics may be controlled by requiring 
one year's residence, with satisfactory class standing, before 




Fig. 170.— The march past of the football squad (Athletic Pageant, University of Penn- 
sylvania, igi3)- 

allowing a man to represent the university in intercollegiate 
athletics. About 60 per cent, of the colleges have this one-year 
rule more or less rigidly enforced, while about the same per- 
centage of colleges debar graduate and special students and 
students in the professional schools from representing their 
institution.^ 

In rough games like football there will always be accidents 

1 F. W. Nicholson, "Report on College Athletic Administration," December, 
191 2 (National Collegiate Athletic Association). 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 265 



to deplore. The chance of a twisted ankle or knee, a broken 
collar-bone, arm, or leg, or even concussion of the brain, is one of 
the things that make such games attractive to the healthy and 
courageous young man ; but if we put against these accidents the 
escapes that every old player of forty can recall from an injury 
that a clumsy slow movement would have precipitated, the bal- 
ance will surely be on the other side, and permanent disability 
from accident is comparatively rare in men who, properly ex- 
amined and found to be sound, are sent into 
a contest well prepared by an adequate 
course of training. 

The director of the department of physical 
education should be a college-bred man, pre- 
ferably a physician, who, in addition to his 
medical training, has had practical experience 
in athletics and gymnastics.^ An analysis of 
the training of college directors of physical 
education, made so long ago as 1908 by 
Clarence Baker, ^ showed that about 80 per 
cent, have held captaincies of teams, while 
one-half have been team managers during 
their undergraduate Ufe. With this training, 
he should also have enthusiasm," interest in 
men, patience, determination, and ability to 
lead. He should not be without a good phy- 
sique. In smaller colleges he should be able 
to coach one or more teams himself, while in 
large institutions, where this is impossible, 
he should be able to organize and direct his 
staff of examiners, instructors, and coaches, 
and conduct the teaching through them and a corps of class 
leaders or voluntary student assistants, the organization of 
which is a most important part of the departmental machinery. 




Fig. 171.— A class 
leader (University of 
Pennsylvania) . 



1 T. A. Storey, "Technical, Academic, Professional Training Needed on the Staff 
of a Department of Physical Education," P. E. Rev., vol. xiv, p. 6. 

2 Thesis, Springfield College. 



266 



EXERCISE IN EDUCATION AND MEDICINE 



At Pennsylvania candidates for class leadership receive one 
period a week of extra instruction in addition to their regular 
gymnastic class work. After serving one year they receive a star, 
to be worn on the g^innasium shirt, in addition to the bar of rib- 
bon which is their distinguishing mark; after two years, another 
star; and during the third year they attend a course of ten lec- 
tures on the theory of physical training, which is followed by a 
written examination and an examination in practice of gymnastics 
and leadership on the gymnasium floor. Upon the successful 
passing of these the student receives the insignum of the leaders' 
corps and a certificate. In addition to this, members of the 




172. — Floor talk before the beginning of class (College of the City of New York). 



athletic teams act as volunteer assistants for the classes in track 
and field sports. 

Practically, all colleges and universities that have such a 
department organized give some instruction in the theory of 
physical training and personal hygiene, their courses forming 
part of the regular teaching, either elective or compulsory, while 
the application of exercise and massage in medicine and surgery 
now has a recognized place in every well-equipped medical 
curriculum. Doctor Storey of the College of the City of New 
York gives every class a floor talk of ten minutes once a week, 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 267 

in which he discusses the common causes of disease, the carriers 
of disease, the defenses against disease, and the nature of the 
more common diseases. The theory of cleanHness and health is 
illustrated and made to apply to the dirty uniform and the soiled 
towel. At Haverford Professor James A. Babbitt gives a course 
on the theory and practice of gymnastics, consisting of anatomy 
and physiology as applied to exercise, together with the practical 
application of exercise. The lectures are accompanied by prac- 
tical laboratory work, and the final examination includes a two- 
hour written test counting 60 per cent., and a practical examina- 
tion on the gymnasium floor counting 40 per cent. At Princeton 
the freshmen have a course on personal hygiene, including the 
influence of diet, exercise, and bathing, the effects of alcohol, 
tobacco, venereal disease, and a study of the more common in- 
fections from Professor Raycroft. Dr. Meylan has courses on 
hygiene and physical education counting as required work at 
Columbia. Similar courses are given at the University of Ne- 
braska and elsewhere. At Wisconsin Professor Ehler has organ- 
ized a course in theory for teachers that counts toward the 
college degree. At Pennsylvania a course on the theory of 
physical education is given to postgraduates in the course on 
public health. Another course, q,lready referred to, is given to 
class leaders, and two lectures a week throughout the year on 
the therapeutic appKcation of exercise to students in medicine. 
Summer courses on physical education, of about six weeks, 
for students, teachers, playground supervisors, and social 
workers, have been given for the last twenty years at Harvard, 
where it began with a one-season course, and is now extended 
over three summers of progressive work in theory and practice.^ 
Summer courses are also given at Columbia, McGill, Pennsyl- 
vania, Wisconsin, and University of California. Owing to the 
imperfect and superficial training received by most teachers of 
physical training these summer schools are most valuable and 
deservedly popular. 

^ "Contributions of the Hemenway Gymnasium to the Cause of Physical Educa- 
tion," Harvard Illustrated Magazine Supplement, vol. xiv. 



268 



EXERCISE IN EDUCATION AND MEDICINE 



In addition to the supervision of the health and the teaching 
of the students, a department of physical education should seize 

its unusual opportunities 
for original research in 
psychology, physiology, 
and anatomy, and asso- 
ciation with other depart- 
ments in solving them 
should not be neglected. 
The occurrence of phys- 
ical defects in the sup- 
posedly normal, investi- 
gation on heart and lung 
conditions, and the effects 
of different forms of ex- 
ercise both on the body 
and mind can be studied 
here to advantage. A 
list of such investigations 
is contained in the Reg- 
ister of the Society of 
Directors of Physical Ed- 
ucation in Colleges. 

The taking of certain 
measurements from time 
to time is useful to stim- 
ulate in the student a 
pardonable pride in his 
expanding chest and swell- 
ing biceps, but it is also 
of use to determine the 
proportions of the average 
student and his variations from this average. Hitchcock, Seaver, 
and especially Sargent, have done pioneer work on this subject. 
Dr. Sargent's complete set of charts, containing the principal 
measurements of students for each year from sixteen to twenty- 




Fig. 173. — The ideal college athlete 
R. Tait McKenzie.) 



(Copyright, 



PHYSICAL EDUCATION IN COLLEGES AND UNIVERSITIES 269 

five, and selections from his statistics for the youth and maiden 
of twenty-one, have been embodied in two hfe-size statues 
modeled by Henry Kitson, showing the medium measurements 
for that age. The variations from that type have been noted by 
Doctor Paul C. Phillips, in his observations on sprinters,^ by 
the author in speed skaters,^ and by Doctor Sargent in his 
"Physical Proportions of the Typical Man" and "Physical Char- 
acteristics of the Athlete."'^ 

The search for a physical ideal was undertaken by the 
Society of Directors of Physical Education in Colleges, who, in 
1902, commissioned the modehng of a statuette embodying the 
average measurements and proportions of the pick of the student 
body, selected by taking the best fifty men in the all-around 
strength test for a period of eight years. These 400 sets of 
measurements of Harvard students, supplied by Doctor Sargent, 
were used to determine the proportions of the typical college 
athlete (Fig. 173), who is represented as placing in his right hand 
the spring dynamometer with which he is about to test his 
grasping muscles. This youth may be said to embody the pro- 
portions and girths of the physically ideal American student of 
twenty- two. With a height of 5 feet 9 inches he carries a 
weight of 159 pounds. The girth, of his neck, knee, and calf are 
the same, with the upper arm i^ inches less. The girth of his 
thigh is ^ inch less than that of his head. His expanded chest is 
40 inches, the girth of his waist 10 inches less, his hip girth almost 
the same as his unexpanded chest, while the breadth of his waist 
barely exceeds the length of his foot, and the stretch of his arms 
measures 2 inches more than his height. 

1 Outing, May, 1903. 

^ Popular Science Monthly, December, 1905. 

^ Scribner's, July and November, 1887. 



CHAPTER XV 

PHYSICAL EDUCATION IN GIRLS' SCHOOLS AND 
WOMEN'S COLLEGES 

Physical education for women too often follows slavishly 
the scheme planned for men, not because it is best for women, 
but because it is the same. This is a deplorable mistake, be- 
cause bodily training of the two sexes must differ radically in 
order to fit each for its own future life and environment. 

A woman's training should develop those characteristics of 
growth, poise, speech, carriage, and dress pecuUar to her, and 
cannot with impunity ignore the psychologic and physiologic 
differences between the boy and the girl and between man and 
woman. 

Even at the age of eight or nine girls begin to work out their 
own set of activities and their social plays and games, individual, 
competitive, and co-operative, by which they secure self-con- 
fidence, skill, and control. At twelve or thirteen the co-opera- 
tive spirit appears in her, although in a much less-marked degree 
than it does in boys. 

Owing to the necessities of modern conditions, in which so 
many women are required to hold their place in commercial, 
professional, and political Kfe, this spirit of co-operation must 
be encouraged, and the team games, requiring obedience to a 
leader, and team work as opposed to individual play, are of in- 
estimable value for this purpose. 

The first twelve years of a girl's life need differ very httle 
from that of her brother's in physical habits. She may lead the 
same outdoor life, climbing, swimming, running, playing ball, 
without distinction as to sex, and nothing will prepare her so 
well for the great physical and mental change which takes place 
270 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 271 

with the attainment of puberty. Outdoor games and exercises 
estabhsh nervous stabihty and poise, and give the best possible 
foundation on which to build her future womanhood. For reasons 
largely beyond her control, those occupations that involve the 
use of large muscle groups have been taken away from the girl 
and the woman even more than from the boy, and she is hemmed 
in on every side by limitations of social usage, dress, and deport- 
ment, and confmed to occupations requiring smaller and more 
monotonous movements, such as running a loom or sewing- 
machine, manipulating a typewriter or telephone exchange, 
piano practice, or reading, all of which require her to sit still 
for long periods, in addition to continuous close attention and 
nervous strain. This muscular starvation and nervous tension 
cannot but cause an abnormal, supersensitive, and morbidly in- 
trospective condition, for which no better corrective can be 
given than the athletic games and sports in which no oppor- 
tunity for reflection or analysis of the feelings is allowed, where 
the great muscle masses of the body are exercised in long, free, and 
sweeping movements, and the circulation drawn out from the 
abdominal organs and spine and distributed to the muscles, lungs, 
and heart. As Dr. Anna M. Galbraith^ says, "Every girls' school 
and women's club which provides for games and sports erects 
barriers against nervousness, morbidity, and introspection." 

Boys are taller and heavier than girls from birth up to about 
the eleventh year. Girls then begin a period of rapid growth 
and soon pass them both in height and weight, maintaining 
this physical advantage until about the fifteenth year, when 
the more slowly maturing boy catches up, and from that time 
forges ahead both in height and weight as well as in strength, 
so that at maturity he has an advantage of about 4 inches in 
height and from 20 to 30 pounds in weight, with strength to 
correspond. 

At maturity woman has a relatively longer trunk and shorter 
legs, less muscular, but more adipose tissue about the hips and 
thighs and a much smaller lung capacity. The shoulders are 

^ Personal Hygiene and Physical Training for Women (Saunders & Co.). 



272 



EXERCISE IN EDUCATION AND MEDICINE 



narrower and more sloping, the bones lighter, and the chest 
much less muscular. The center of gravity in the body is lower, 
and all these differences put women at a distinct disadvantage 
in exercise where weight is supported by the arms, while all 
exercises in which speed with endurance is required quickly 
tell on the smaller lung capacity. Series of measurements, ex- 





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Fig. 174. — Height and weight of boys and girls from birth to twenty-five years: A, 
Height of boys; B. height of girls; C, weight of boys; D, weight of girls; E, percentage 
of growth for various years (Bowditch). 

tending over forty years, show that the increased exercise and 
outdoor Hfe to which young women have been admitted in that 
time have added i inch to their height and about 5 pounds 
to their average weigl-^, but, making every allowance for lack 
of practice and play traditions, they cannot possibly hope to 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 



273 



do more than give a feeble imitation of what men will always 
do infinitely better. 

Comparing the athletic records made by women with those 
made by men one is impressed by the fact that they are not 
really comparable. 

The best running broad jump of 15 feet 3 inches is not much 
more than one-half the distance cleared by a man in the same 
event. The high jump is 4 feet 6 inches for women and 6 feet 
7 inches for men. The record 100-yard dash was run in 12 sec- 
onds by a woman, which is not very fast when compared with 
the 9|- seconds of the college man. 




Fig. 175. — Drill in the movements of fencing by a class of teachers in training. (Courtesy 
of Miss Amy M. Homans.) 

Women cannot stand prolonged physical or mental strain 
as well as men, but with frequent rests they can in the end 
accomphsh almost as much. Certain games, such as football, 
boxing, pole vaulting, and heavy gymnastics, are obviously 
unsuited for their temperament and build, but in dancing, 
swimming, calisthenics, archery, skating, and fencing they 
come much more near to competing with men on equal terms. 
While they are less adapted for arduous muscular work, their 
larger amount of fat enables them to stand exposure to cold and 
moderate physical hardship of long duration even better than 
men. Their vital endurance is better, so that the disadvantages 



2 74 EXERCISE IN EDUCATION AND MEDICINE 

they have in other activities is made up for by this greater 
tenacity to hfe. 

As a general rule, girls are not naturally fond of sports and 
games. They have much less of the spirit of adventure or com- 
bat than boys, although they have more of the spirit of romance. 

One of the first difficulties noted by Miss Harriet Ballentine 
of Vassar^ was to reaHze how very little exercise the student 
would take if left to her own inclination. A small minority were 
enthusiastic, a much larger number would exercise if the work 
was pleasant, but were usually poor in practice, and a larger 



Fig. 176. — A Swedish drill by a class of teachers in training. (Courtesy of Miss Amy M. 

Homans.) 

number were interested only in seeing the others work. This 
condition has changed for the better in recent years. 

Provision has always been made in most women's colleges 
for some form of exercise, usually light and innocuous calis- 
thenics, alternating with the "crocodile," the familiar formal 
procession in twos, with a pair of teachers at the tail. We 
find reference to this method, which is still to be seen in most 
convents and boarding-schools, as early as 1837 at Mount 
Holyoke, v/here one hour daily of such exercise was taken, and 
the calisthenic movements used were collected and printed by 
1 P. E. Rev., vol. V. 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 275 

Miss Titcomb (1853) .^ Many of the steps which closely resembled 
dancing were introduced as calisthenics, so that the prejudice 
against this godless art should not take active form. In 1862 
the "New Gymnastics" were introduced. This system, gath- 
ered from German and Swedish sources, developed and elab- 
orated by Dio Lewis with many exercises of his own inven- 
tion, seemed peculiarly suitable to a girls' school. They se- 
cured attention, enthusiasm, accuracy, and a good posture and 
gait. About 1875 boats were given to the school, and tennis 
was introduced, while the three under classes were required to 
do gymnastic work from November to June. In this way boat- 
ing and tennis began to supplement the monotonous walk. In 
189 1 gymnastics were changed to include Swedish work and 
outdoor games; fencing and basket-ball were introduced. An 
athletic association now took charge of hockey, skating, tennis, 
and other outdoor games. 

Similar growth can be shown at Vassar, at Bryn Mawr, and 
at Wellesley. 

In 1 89 1 physical training was introduced at Wellesley, with 
three hours a week of instruction in the gymnasium for fresh- 
men, under the direction of Lucille Hill. 

Boats were bought and crews were organized among the 
students to row on the lake. The recording and tabulating of 
vital statistics was undertaken by Dr. Anna M. Wood, and the 
comparative tables showed satisfactory increases in the girth 
and depth of the chest, the lung capacity, and other items after 
exercise. 

In 1909 the Boston Normal School of Gymnastics was affil- 
iated with Wellesley College, becoming the Department of Hy- 
giene, with required work having credit toward the B. A. degree; 
and the present most efficient system was introduced by its dean, 
Miss Amy Morris Homans. 

Outdoor sports at Vassar are a special feature, and the 
gymnasium and playing fields at Bryn Mawr are kept actively 
employed, while in co-educational institutions, hke Wisconsin, 

1 P. H. McCurdy, P. E. Rev., voL v. 



276 



EXERCISE IN EDUCATION AND MEDICINE 



Chicago, California, and Michigan, equal provision is made 
for men and women. 

The physical examination that should precede every course 
of exercise given in a women's college should vary somewhat 
from that suitable for men. An analysis of the examination 
blanks used at seven of the most prominent women's colleges 
shows that emphasis is placed in discovering disabihties that 
would prevent exercise, or that may be improved by it, rather 
than the estimation of strength and physical efficiency. Besides 
questions about sleep, digestion, and general health, the history 




Fig. 177. — Field hockey game at University of Wisconsin. (Courtesy of Miss Blanche 

M. Trilling.) 



and regularity of the menstrual function is carefully inquired 
mto. Irregularity is frequently the result of a disturbed cir- 
culation and digestion, and may, in many cases, be improved 
by judicious exercise. Inquiries are made about the wearing of 
corsets, braces, or any other form of confining clothing. Stress 
is laid upon the condition of the feet and spine, the heart, lungs, 
vision, and hearing. The measurements are usually fewer in 
number than in the examination in men's colleges, but should 
include height, weight, girth of chest during inspiration, girth of 
the waist and hips, depth of the chest and waist, and a test of 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 277 

the strength of the back, legs, forearms, concluding with the 
lung capacity.^ 

The history blank employed at Wellesley is exceedingly 
elaborate and comprehensive. When the student comes to 
college she receives an appointment for examination. At the 
appointed hour she removes her clothing in a dressing booth, 
takes down the hair, puts on a fresh white gown, which is sup- 
plied her, and a bath robe. The student is then seated on a 
revolving stool and the medical examiner notes the nutrition 
and general condition. The bath robe is then discarded and the 
patient reclines on a table. The chest and abdomen are pal- 
pated and the patellar reflexes tested. The student then stands 
up barefooted, and the back, shoulders, and hips are inspected 
for curvatures and unevenness, the feet for abnormalities, and 
a few measurements are taken. 

In these supposedly normal young women the most fre- 
quent orthopedic defect found was pronated ankles (70 per 
cent.). This large percentage is attributed by the examiner to 
the habit of instructing children to toe out and to faulty foot- 
wear, as well as to constitutional weakness ; 53 per cent, showed 
uneven or round shoulders, with uneven hips in 43 per cent., 
and curvature in 35 per cent. Most of these were remediable 
by corrective work in the gymnasium. Chronic defects of the 
hearing were found in only 2.5 per cent. Congestion of the 
nasal cavities occurred in about 13 per cent., while the throat 
conditions were abnormal in 28 per cent. Only i per cent, of 
these young women had poor or irregular teeth, which is inter- 
esting as showing the value placed by the average American 
young woman on the care of her teeth. The lymph-nodes were 
enlarged in about 12 per cent., but only three of them were suf- 
ficiently large to require attention. About 16 per cent, showed 
enlargement of the thyroid gland, most of them coming from 
the thyroid district, which includes Michigan, Illinois, Iowa, and 
Kansas. Certain nervous manifestations, such as biting the 

^ "Medical Data on Supposedly Normal Women at Wellesley," V. M. Canavan, 
M. D., Medical Examiner at Wellesley, P. E. Rev., November, 191 2. 



278 EXERCISE IN EDUCATION AND MEDICINE 

nails, twitching of the facial muscles, choreiform movements, 
and nervous instability, as shown in weeping and fainting spells, 
were also found; 28 per cent, showed some heart murmur, 
usually without enlargement. 



BRYN MAWR COLLEGE HEALTH DEPARTMENT 

SPORTS LIST 

Miss _ : is classed as C. 

MAY play ONLY the sports not crossed off on this card. 

Hockey. Goal, ist team. Fullback and goal 2d, 3d, or 4th team. 

Archery. Easy tennis and swimming. 

Goal or full in soccer. Throws in track. 

MAY NOT enter any other sports, or any meets, tournaments, or matches 

without first obtaining a special Authorization Card. 

Signed 

Date 



For the examination of those girls who wish to compete for a 
place on the college crew, hockey, baseball, tennis, and golf 
teams, or in track athletics, the following method is now in 
force. All who are sufficiently sound at the preliminary examina- 
tion and have had no illness since, and who are doing regular 
gymnasium work, are certified without further examination. 
Those doing corrective or light gymnastics are re-examined. 
Those who have not attained an "A" in their gymnasium work, 
or who are reported to have been ill or previously disqualified, 
are re-examined. No one is disqualified except when it is ab- 
solutely necessary, and only 3 per cent, of those wishing to take 
part in sports have been restrained from engaging in them. 

The onset of menstruation occurred before thirteen years in 
17 per cent., before twelve years in only 5 per cent., while some 
menstrual irregularity was found in 23 per cent. 

Dr. Clelia Mosher,^ Medical Examiner at University of Mich- 
igan, in speaking of the relation of exercise to the menstrual 

^ P. E. Rev., vol. xvi. 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 279 

period, is of the opinion that the percentage suffering from 
disabiUty is much less than is generally supposed, and that 
much of the pain is due to the attention which is unfortunately 
directed to this function. "Until we can treat this periodic 
flow as an accident rather than the central idea of life," she 
says, "morbid apprehension will continue to produce general 
disability." Her opinion is strengthened by the extensive in- 
vestigation made by Dr. Angenette Parry. ^ Her questionnaire, 
addressed to leading obstetricians, college physicians, and direc- 
tors of physical training, and to others who have the supervision 
or who engage in regular and strenuous physical exercise, brought 
out some interesting facts on this subject. The consensus of 
opinion was that girls may indulge in physical sports and games 
to a considerable extent during their periodic sickness, but 
should refrain from exhausting athletic contests or competition. 

With some few exceptions girls accustomed to athletics or 
gymnastics could continue exercise without detriment during 
menstruation. In the majority of cases the flow was increased 
by gymnastic exercises, but in one circus gymnast it was less- 
ened. None of these professional circus performers who were 
interviewed desisted from their exercises during their periods. 

As to the effect of systematic exercise as a preparation for 
normal child-birth, forty answers from physicians showed that 
athletic patients got along much better and more than one-half 
believed that athletic exercise in moderation favors easy labor. 
Most of them agreed that convalescence was quicker. Five out 
of twenty gynecologists consulted believed that pelvic displace- 
ment could be caused by violent exercise, but the consensus of 
opinion was that it did not produce it, and by some it was recom- 
mended as part of the treatment for this condition. 

It is probable, then, that athletics indulged in moderately 
and under proper supervision are not dangerous to girls and 
women even during their periods, and it is only the more strenu- 
ous competitive athletics in which the futile attempt is made 
to imitate the more violent sports of boys and men that the 

1 American Journal of Obstetrics, September, 1912. 



28o 



EXERCISE IN EDUCATION AND MEDICINE 



danger is likely to arise. This is borne out by the long and care- 
ful observations of Dr. E. H. Arnold, Principal of the New 
Haven Normal School of Gymnastics, who has had unusual 
opportunities of observing large numbers of girls engaged in 
regular and exacting daily exercise. His opinion, fortified by 
many statistics, coincides with the one just stated.^ 

Girls should be divided into groups according to their abil- 
ity for exercise. Those in whom certain marked defects are 
present are taken either individually or in small squads for 
special movements aimed at the correction of their fault. Flat- 
foot, lateral curvature, unusually weak muscular development, 
weakness of the abdominal walls, tendency to hernia, flat chest, 




Fig. 178. — Dancing steps to music by a class of teachers in training 

Amy M. Romans.) 



(Courtesy of Miss 



and other such deformities should be vigorously treated in this 
way during a college girl's Kfe. For the general gymnastic class 
work, emphasis should be laid upon rhythm and music. They 
do not require the prolonged and exhausting attention that 
Swedish gymnastics demand. 

Esthetic dancmg, as developed by the late M. B. Gilbert, 
beginning with the five fundamental positions of the feet and 
the arms, with its attitudes, arabesques, and poses, deservedly 
occupies a large place in a course. Nothing is so valuable for 
freeing the awkward and stiff carriage of the body, bringing the 
shoulders back into place and giving an easy and elastic tread 

1 P. E. Rev., 1Q14. 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 



2»I 



in walking. Under its influence weak backs are straightened, 
and students gain in alertness, co-ordination, and judgment as 
well as agility, and, above all, in rhythm. 

The "Eurythmic Gymnastics" of Jacques Dalcroze, de- 
scribed in Chapter IX, carry this training in rhythm to a 
much higher i)oint, and bring the teaching of gymnastics and 
music together in a way that gives joy and exhilaration to what 
is usually dry and uninteresting. The animation and gayety 
obtained from these means are strong points in their favor. 




J'iK. 170- 



-DancinR in the spring i)aKe;int at University of Wisconsin. (Courtesy ol Miss 
Blanche M. Trilling.) 



Closely allied to these exercises are the folk dances, Morris 
dances, and pageants, in which exercise is put in a form that is 
beautiful, and may even be symboHc and approach the art of 
pantomine, appealing to the esthetic and romantic side of a 
girl's nature as well as to the joy of mere physical expression. 

It is more particularly for girls and young women that the 
gymnastic principles laid down by George Demeny, of France, 
and described in Chapter IX, apply, and anything which 
is angular or which involves holding fixed positions for long 
periods of time should be avoided. Exercises on fixed appara- 
tus in which the weight is balanced or handled by the arms 
should be avoided, as a rule. The musculature and proportions 



282 



EXERCISE IN EDUCATION AND MEDICINE 



of women give them a peculiar disability for such work as the 
parallel bars, the horizontal bar, and the flying rings, and those 
who do succeed have always a masculine build. On the other 
hand, exercises on the balance beam, the trapeze, or even on 
the slack rope are both graceful and valuable to teach equilib- 
rium and muscle control, and the stretching of the body through 
the swinging on the travehng rings is most valuable. Class run- 
ning, jumping, and vaulting are good if care is taken to provide a 
soft landing place. 




Fig. 1 80. — A contest with the hurl-ball at University of Wisconsin. 

J. C. Elsom.) 



(Courtesy of Dr. 



Dr. Sargent of Harvard believes that no athletic sport need 
be barred for fear of injury, and all are practised by his students, 
but undoubtedly the feminine type of figure is a handicap in 
many athletic tests. Gymnastic games are of the utmost value. 
Basket-ball, playground ball, and dodge ball cultivate co-ordina- 
tion, speed, activity, and co-operation, and should be encour- 
aged. Public competition in a game like basket-ball tends fre- 
quently to run riot, and the nervous excitement caused by inter- 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 



28: 



collegiate or interscholastic competition, together with the pub- 
licity of them, is distinctly a bad influence. It also means that 
members of the team may be called upon to play when they 
are in no physical condition for such a test. Among the least 
objectionable contests is that with the hurl-ball, in which the 
movement is free and graceful and not too severe. 

Outdoor exercise should vary from walking, preferably over 
broken ground and with some object in view, such as botanizing 



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Fig. iSi. — Class in archery, University of Wisconsin. 

Trilling.) 



(Courtesy of Miss Blanche M. 



or the study of birds or rocks, up to a game like field hockey, 
perhaps the finest outdoor game for girls, introduced and popular- 
ized in American colleges by Miss Constance Applebee of Bryn 
Mawr. Such games as tennis and golf are ideal, but the team 
play required in hockey or even association football gives them 
an added value, although the number who will practice them 
voluntarily will always be limited. 

Individual competition in track athletics is, I believe, a 
thing to be discouraged. It is seldom that girls will of their own 



284 EXERCISE IN EDUCATION AND MEDICINE 

volition put the shot, do high or broad jumping, or even run a 
100-yard dash, and when they do so it is usually done without 
conviction and in imitation of their brothers. 

Archery cultivates a good posture, and is a graceful, interest- 
ing, and exhilarating exercise that should be more practised than 
it is. It is popular at Wisconsin and Wellesley; so is the pitch- 
ing of quoits and bowling. 

Swimming is one of the best exercises for women, calling 
into action most of the muscles of the body, but sparing those 




Fig. 182. — A University of Wisconsin student pitching quoits. (Courtesy of Miss 

Blanche M. Trilling.) 

of the back so commonly overworked in the standing and sitting 
postures. Women stand the cold much better than men, but 
the instructor must always be on the lookout for the appearance 
of blue lips, pinched face, and shivering limbs, a warning to 
come out. The water should be kept at about 70° F., and fans 
for rapidly drying the hair have made swimming more popular 
than it was. 

At Vassar gymnastic work begins in November and con- 
tinues until the end of March. The wands and dumb-bells 
vary in weight from 12 ounces to 2| pounds, but are used for 



PHYSICAL EDUCATION IN SCHOOLS AND COLLEGES 



285 



special classes only. Instruction in classic dancing is an impor- 
tant part of the course, as is swimming. Students learn to swim 
in six lessons on an average. 

Outdoor sports like hockey occupy three hours a week in 
October, and in the spring the list of elective games includes 
croquet, lawn tennis, basket-ball, 
rowing, and riding, which is chosen 
yearly by about 200 of the students. 
Riding lessons begin at any time 
throughout the year. A man's saddle 
is used, but somewhat narrower and 
with a higher front. During their 
periodic sickness girls are forbidden 
to take part in any athletic exer- 
cise. 

The gymnastic dress is a bloomer 
costume and jumper, with long stock- 
ings and thin fiat shoes without heels. 
The costume is loose and cut low at 
the neck, with sleeves to the elbows. 

In conclusion, I may say that an 
important duty of the department of 
physical education and hygiene of a 
girls' school or college is to supervise 
the amount and nature of their rest, 
as is now done at Wisconsin and at 
Wellesley. It is quite as important 
to prescribe an hour of absolute 
rest recumbent for a student whose 
nervous and muscular system is 
overwrought, and in whom hysteria 
is imminent, as it is to recommend and supervise her exercise. 

By providing, then, for her physical care from absolute 
rest to the most active competition, a department of physical 
education will fulfil the duty that the college owes to every 
young woman put in its charge. 




Fig. 183. — Bloomer costume for 
women (Galbraith). 



CHAPTER XVI 

THE PHYSICAL EDUCATION OF THE BLIND AND 
THE DEAF-MUTE 

Having described the physical education of the normal child of 
both sexes from infancy to maturity, there remains only a descrip- 
tion of the modifications required for the training of those un- 
fortunates to whose minds the avenues of sight and hearing are 
closed; and of those others whose minds are dulled or who have 
already taken the first steps in the path that leads to the peni- 
tentiary or the mad-house. 

Since the world of the blind is Hmited by the horizon made 
by the reach of his arms, his supremacy within this circle must 
be supreme. 

Physical education does him a triple service by increasing 
the courage and confidence which he so sadly lacks, by develop- 
ing his muscular powers, and by fortifying his body against those 
infirmities to which enforced idleness and a sedentary habit 
render him peculiarly prone. 

It is within comparatively recent years that the physical edu- 
cation of the bhnd has been studied with care, and that methods 
have been adapted to their possibilities and limitations. 

The most striking characteristic of the bhnd child is a cer- 
tain timidity or fear of appearing at a disadvantage before 
others, especially in making an unaccustomed movement, so 
that the only exercise they undertake voluntarily is walking 
backward and forward in some confined place with which they 
are familiar. They are liable to sit still for long periods of time, 
and usually develop certain rhythmic habit movements of the 
head and hands difficult to repress and correct. 

They must either feel or hear a movement in order to learn it, 
286 



PHYSICAL EDUCATION OF BLIND AND THE DEAF-MUTE 287 



for they have not the mirror 
of their companions from 
which to correct faults in their 
own posture or action. 

In the measurement of 
boys at the Overbrook School 
for the Blind it was found 
that their height, weight, and 
lung development were under 
the average of normal boys 
of the same age, as shown 
in the Sargent charts (Allen). 
The bhnd boy has thus even 
a greater need for physical 
training than the boy who can 
see. 

In many bhnd children ex- 
ercise must begin with the 
simplest acts, such as dressing 
and undressing, which have 
been neglected in many homes 
where the blind child is waited 
on and not trained in move- 
ments that make for accuracy 
and tidiness. 

A course must pay special 
attention to the improvement 
of posture in walking, stand- 
ing, and sitting, for the blind 
walk with the head inclined 
forward, the chest contracted, 
and usually come down hard 
upon their heels at each step. 
It must embrace free move- 
ments for the chest, arms, 
and shoulders, including all 



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288 EXERCISE IN EDUCATION AND MEDICINE 

possible games and other forms of reaction that can be conducted 
with safety and abandon. 

The chief difficulty in such a course is the cultivation of 
that physical confidence necessary for success in active sports 
like running, jumping, and gymnastics. 

Various devices are required in the construction of the gym- 
nasium and field to prevent accidents and to foster freedom of 
movement. The gymnasium hall should be constructed with a 
wooden floor, surrounded by a band of cement 7 feet wide, 




Fig. 185. — The cock-fight and other gymnastic games. The band of concrete at the 
edge of the floor is also shown (Pennsylvania Institution for the Instruction of tlie Blind, 
Overbrook, Pa.). 



on which all the heavy apparatus should be placed when not in 
use (Fig. 185). In this way a blind person is made aware of his 
approach to the wall, and of the presence of danger, when 
walking, running, dancing, or skating. A running track should 
have a hand-rail of convenient height to serve as a guide, and 
in the play-fields the presence of trees should be shown by hav- 
ing a brick walk about 10 feet in front of or around them, so 
that the child may run and play with perfect freedom and con- 
fidence until warned of the approach to danger by the bricks 
under foot (see Fig. 184). 



PHYSICAL EDUCATION OF BLIND AND THE DEAF-MUTE 289 

Outdoor apparatus should also be fixed, the child soon learn- 
ing their place, and avoiding the colhsions that would inevitably 
occur if their position were a matter of conjecture. 

Physical education for the blind should be compulsory at 
all institutions as it is at Overbrook, Pa., the classes being small 
and arranged in the order of their age, and with some partially 
blind pupils mixed with the totally blind to act as leaders. 
In his classes for blind in the Milwaukee Pubhc Schools Wittig 
confined the number to 12. The formation of a class in the 
gymnasium need not differ very much from that of children with 




Fig. 186. — Method of alignment in a class of the blind in Sweden (Lefebure). 



sight, except that in lining up they should keep in touch with 
one another by each pupil placing the hand on the shoulder of 
the one in front, or, where a class is formed up in ranks, by plac- 
ing the right hand on the companion's shoulder and the left 
hand on the waist, as is done in Sweden (Fig. 186). 

When a number are lined up in single file a regular class 
formation can be obtained without difficulty by giving the 
order "right turn," and counting off, and this can easily be 
reversed to the original line-up when the exercises are over. 

Gymnastic apparatus work may be used with considerable 
19 



290 



EXERCISE IN EDUCATION AND MEDICINE 



advantage, but the leader should be able to see a little, and 
members of the class must learn the movement by passing the 
hand over the leader while he is doing it. By this means a wide 
range of work can be done on the horse and parallel bars, and 
such exercises as falling, rolhng, and simple tumbling may be 
extensively developed, but the Swedish gymnastics, in which 
the exercise is performed in response to command, must be 
used sparingly, because of the great and rapid mental exhaustion 
produced in blind children. 




Fig. 187. — loo-yard dash. Start, showing handles and cables to direct their course. 
Overbrook record, 100 seconds (Pennsylvania Institution for the Instruction of the Blind, 
Overbrook, Pa.). 



Music has a peculiar value in cultivating confidence and 
rhythm, both of which is sadly lacking in the blind. 

Formal gymnastics and apparatus work should play, how- 
ever, a comparatively small role in their day's exercise, and 
games should be freely interspersed when symptoms of exhaus- 
tion appear. Among the most popular games is the cock- 
fight, and a game invented at Overbrook by Lindblad, called the 
Japanese torpedo, in which a small bag of sand covered by 



PHYSICAL EDUCATION OF BLIND AND THE DEAE-MUTE 291 

emery cloth is attached to a long string, and swung around in a 
circle by one pupil while the others jump over it as it passes, 
being guided by the sound of the emery cloth on the floor. 

The soft rubber baU is a valuable piece of apparatus. Throw- 
ing and catching it, bounding it against the floor or wall, have 
an unending interest (Wittig). 

Running, roller-skating, and dancing can also be practised 
if comparatively few skaters or dancers are allowed on the floor 




Fig. 188. — 100-yard dash. Finish. The racers are able to give unhampered atten- 
tion to speed by means of the device shown above. Upon the wire cables, stretched the full 
length of the track, are rings to which are attached short chains and handles. The racers 
hold these handles and run the course with perfect freedom. They are warned of the end 
of the track by the fringe of cords like that used on railroads to notify brakemen on top of 
freight cars of "low bridges" (Pennsylvania Institution for the Instruction of the Blind, 
Overbrook, Pa.). 

at one time, and all are required to circle in one direction only, 
the presence of the concrete margin on the floor being sufficient 
protection when heavy apparatus is carefully put back in its 
place against the wall after class use. Another protection against 
running into the wall is the changed resonance due to the presence 
of the running track, a phenomenon which the blind use con- 
tinually for their protection. 



292 



EXERCISE IN EDUCATION AND MEDICINE 



Among the outdoor sports walking is almost the only one 
blind children will voluntarily undertake, although they can be 
taught almost all the held sports, with but few restrictions. 

- Clarence E. Van de Walker, the in- 

structor at Overbrook, writes on this 
subject: 

"To me, watching and directing this 
work from day to day, the sight of 
strong, active boys, learning to run in 
much the same way that a baby learns 
to walk, and experiencing about the 
same difhculties, was both amusing and 
pathetic; but the smile and shout of 
triumph which burst forth simultan- 
eously from the boy who had succeeded 
in really running were ample proof of his 
delight to discover that he possessed a 
power dormant so long that he doubted 
its existence." 

Foot-racing was practically impossi- 
ble until the invention of a method in 
one of the institutions of Edinburgh, by 
which a three-stranded cable as light 
as was consistent with strength was 
stretched breast high between well- 
guyed end-posts no yards apart. The 
runner holds in one hand a wooden 
handle attached by a short flexible 
chain to the long wire. As he runs 
the ring slips along and the feeling and 
sound enable him to hold his course. At the end of the 100 yards 
a cord is stretched across, about 7 feet high, from which hangs a 
fringe of hammock twine long enough to strike the runner in the 
face as he passes. This fringe covers the two parallel lanes, so 
that competitors may run in pairs, and prevents those accidents 
that were at best too frequent in the open field. 




Fig. 189 



. — Blind boy prepar- 
ing to jump. 



PHYSICAL EDUCATION OF BLIND AND THE DEAP-MUTE 293 

High and deep jumping are practicable, and even the 
running broad jump may be practised, the measurement 
being made from the starting foot instead of from a fixed 
board. 

Other popular field sports are putting the shot, throwing the 
discus, and throwing the hammer — with a stiff wooden handle 
and thrown from a stand. 

A strange phenomenon for the psychologist is the popularity 
of a modified form of baseball, in which, at a signal, the pitcher 
throws the ball, the batter strikes, and the catcher catches. 




Fijg. 190. — Putting the shot (12 lbs.). Overbrook record, 35 ft. 15 in. (Pennsylvania Insti- 
tution for the Instruction of the Blind, Overbrook, Pa.). 

As a rule, no one accomplishes anything but the pitcher, and yet 
boys will play this for hours at a time. Football is also played 
by choosing sides and kicking the ball back and forth until the 
goal-Hne of one side is crossed. This is also popular, and can 
best be done by choosing one, at least, on each side who has 
partial sight. 

Swimming is an excellent exercise for the arms and shoulders, 
and is practised with success among the blind. 



294 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. igi. — The swimming-pool (Pennsylvania Institution for the Instruction of the Blind. 

O verb rook, Pa.). 




Fig. ig2. — Trolley coasting on the athletic field (Pennsylvania Institution for the Instruc- 
tion of the Blind, Overbrook, Pa.). 



PHYSICAL EDUCATION OF BLIND AND THE DEAF-MUTE 295 




Fig. igj. — Ring game. Kindergarten building in the background (Pennsylvania Insti- 
tution for the Instruction of the BHnd, Overbrook, Pa.). 




Fig. 194. — A game of "blind man's huff" in the girls' cloister (Pennsylvania Institution 
for the Instruction of the Blind, Overbrook, Pa.). 



296 



EXERCISE IN EDUCATION AND MEDICINE 



Athletic sports are quite as popular among the girls as they 
are among the boys. They enjoy jumping and running, and 
athletic and gymnastic apparatus, like the trolley-coaster, swings, 




Fig 195. — Rocking boat (Penns>-l\-ania lii~titution for the Instruction of tlie Blind, Over- 
brook, Pa.). 

and see-saws, should be provided for them in the gymnasium 
and out of doors, while the rocking boat is safe and an endless 
source of pleasure to the younger children. 

The Deaf-mute. — A system of physical training designed 



PHYSICAL EDUCATION OF BLIND AND THE DEAF-MUTE 297 

for deaf-mutes must take into consideration the peculiarities in- 
cident to deafness that divide them from the rest of humanity 
into a class by themselves. It must also bear in mind the 
fact that in almost every respect they resemble other children. 
A deaf child thinks in gesture and pictures, and so expresses his 
thoughts, but his verbal memory is undeveloped. His chest and 
all the apparatus of articulation are, in consequence, under the 
average, and they are pecuHarly liable to disorders of the respira- 
tory tract accompanying this underdevelopment. 




Fig. 196. — Deaf-mutes playing basket-ball. 

In girls of sixteen one series of observations by Miss Grace 
Green showed an average lung capacity of 118.3 cubic inches, 
as compared with 130 cubic inches of the normal girl of the 
same age. 

Their powers of co-ordination, particularly of equilibrium, 
are not up to the normal, and they have a peculiar characteristic 
slouch of the figure and a shuffling gait. 

Physical education would then include and emphasize the 
teaching of articulation, which is an art by itself; the develop- 
ment of the respiratory system; the cultivation of balance and 
the correction of postural defects. 



298 EXERCISE IN EDUCATION AND MEDICINE 

The education of the deaf is carried on better in an institu- 
tion than at home, and as the great majority of such cases come 
from the poorer classes, and have to be made as efficient as 
possible as wage-earners, I shall write more particularly of in- 
stitutional work. 

No formal drill should be given to the very youngest pupils, 
who have no ^^language" but games and free play seem, to suit 
them best. To the class next youngest, whose language is limited, 
work should be given by word of command, followed by the exe- 
cution of the movement, which the children imitate. In this way 
the movement of the lips is associated with the exercise, and the 
child is trained to read the lips in such wise as to learn the re- 
sponse to the command without further demonstration. 

The teaching of lip-reading is part of the instruction in 
every institution for deaf-mutes. 

The last census of the United States shows that of 89,287 
deaf, only 13,986 could read the lips, and speech-reading was 
confined almost entirely to the totally deaf, since the partially 
deaf or those who have acquired deafness in later life do not 
learn it, but depend on the use of some device like the ear- 
trumpet in preference. 

About 39 per cent, of the totally deaf have been taught 
lip-reading at institutions Hke Mount Airy, Pa., and elsewhere, 
and as every means is taken to practise the children in this art, 
physical training gives valuable opportunities. 

In the more advanced grades, as their language becomes 
better, the significance of the command is apprehended and its 
full meaning realized. Exercise by word of command is then of 
double value for deaf-mutes, since it teaches lip-reading and 
trains their verbal memory. There are two things to be re- 
membered, however, in teaching a class of deaf children. The 
teacher must always be in front of the class, on a platform ele- 
vated at least i foot above the floor, so that each pupil may have 
a clear view of her mouth without having to lose the correct 
attitude in standing. Commands for marching and turning 
movements must always bring the class back to a position fac- 



PHYSICAL EDUCATION OF BLIND AND THE DEAF-MUTE 299 

ing the platform, as the pupils have only the teacher's face to 
depend upon for direction. Her face should be well Hghted, and 
the commands should be given with full force, so that the natural 
facial expression may be maintained. This, while an advantage, 
is not essential, as I have repeatedly seen a class respond promptly 
and accurately to a command given by the lips only without 
any sound. 




Fig. 197. — The gymnasium at Mount Airy, showing the balance boards for teaching equi- 
librium, in the foreground. 

The shuffling gait and bad posture are corrected by setting- 
up exercises, taken in the standing and sitting positions. Close 
attention should be given to the correct carriage of the head 
and shoulders; to the rhythm and length of the stride; to the 
position of the feet and the distribution of the body weight. 

Balance movements are most useful for encouraging a better 
equilibrium and improving the manner of walking, requiring, as 
they do, a high degree of co-ordination. Whether a lack of co-or- 



300 EXERCISE IN EDUCATION AND MEDICINE 

dination and equilibrium is or is not a direct result of deafness is 
not proved, although in many cases it would appear to be the 
case. 

In a series of experiments conducted by Miss Grace Green, 
at Mount Airy, 60 pupils were chosen from the intermediate 
department of the institution on account of their untrained 
sense of equilibrium. From this number 16 were excluded, classed 
as semideaf. Of those remaining, 27 were congenitally deaf and 
17 were semimutes. Of the 27 congenitally deaf, 20 could sus- 
tain equilibrium with little difficulty and 7 could not, while of 
the 17 semimute, only 2 were able to keep in balance. 

It is also worthy of note that of the 44 cases, 32 were unable 
to maintain equilibrium on the balance beam or board. 

These experiments emphasize the importance of balance 
exercise in the training of the deaf, for they rapidly respond to 
systematic training. 

Deaf-mutes do not compare favorably with hearing people 
in the matter of longevity. They die in a larger proportion from 
diseases due to bad feeding, poor housing, and unsanitary con- 
ditions. Mouth-breathing is exceedingly common among them, 
and there is a high mortality, due to chronic affections of the 
respiratory tract. Great emphasis should thus be laid upon 
good food, warm clothing, the cultivation of speech, and the use 
of respiratory exercises, both free and by the aid of apparatus. 

It is to be remembered that one of the chief characteristics 
of the deaf is the lack of speech. The hearing child who is laugh- 
ing, singing, and shouting in his play all day is unconsciously 
giving to the lungs one of the most healthful exercises. The 
power of speech is a great incentive to the use of the lungs, and 
the acquirement of speech is one of the first things that should be 
taught the deaf child ; it can be greatly aided by exercises of deep 
breathing, together with movements of the arms, chest, abdomen, 
and lateral trunk, with special training in tone production and 
control of the respiration. The patient is thus given increased 
power to resist disease, and acquires better speech through this 
development of the entire respiratory tract. 



PHYSICAL EDUCATION OF BLIND AND THE DEAF-MUTE 301 

Miss Green has shown at Mount Airy a rapid and gratifying 
increase in the chest capacity of the girls of that institution 
under the influence of physical training and instruction in articu- 
lation. Her pupils showed an average lung capacity of 118.3 
cubic inches on entrance, in comparison with the average 130.3 
for normal girls of the same age. With training the average was 
raised to 139.6 cubic inches from one season's work. 

Games and play are used freely, both to relieve the tedium 
of the more formal gymnastic work and to give that development 
which can be produced by free play alone. They differ little 
from the plays of the normal child, and should be designed so as to 
involve the actions of large muscle groups, training the children 
in alertness, decision, and accuracy. 

For boys and young men all the games and sports of the 
normal child are available, and it is not uncommon to see the 
foot-ball or basket-ball team of such an institution taking its 
place with that of a preparatory school or college of the same 
size, although the silence with which they play forms a striking 
contrast to the noise of their opponents. 



CHAPTER XVII 

PHYSICAL EDUCATION OF MENTAL AND MORAL 

DEFECTIVES 

It is during the early years of school-life that the condition 
known as mental dulness, backwardness, arrested development, 
or feeble-mindedness develops sufficiently to be capable of 
definite diagnosis. It is there also that the first steps can be 
taken to correct mental sluggishness and to train the neuro- 
muscular system of these atypical children. The backward 
child is always much older and bigger than the other children 
of his class, hopelessly behind in his standing, usually remain- 
ing two or three years in one grade, and sometimes promoted 
only when the desks and seats of the room have become too 
small for him. 

Mental duhiess may be due to physical weakness following 
severe illness, or to other curable ■ conditions that may not have 
been recognized by the parent or family physician. Again, 
certain children in good physical health develop slowly at cer- 
tain ages, afterward catching up with their fellows. This may 
be due to a period of rapid physical growth, and should be care- 
fully distinguished from the more serious conditions. Teachers 
all recognize a class of children who remain distinctly backward 
for several years. When they wake up, as they eventually do, 
they frequently show unusual ability. When these cases are 
accounted for, and their types of temporary slowness or ab- 
normahty noted, there still remains a group of pupils who, while 
not actually idiotic, are so deficient mentally as to be entirely 
incapable of profiting by ordinary school methods. 

In the examination of 100,000 school children in London in 
1890, Dr. Francis Warner showed over i per cent, of actual 
302 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 303 

mental defectives, and similar investigations show that this 
ratio holds good in America. 

The symptoms of mental deficiency are characteristic. 
Backward children are fatigued by any mental effort and lose 



ACE 6 8 10 12 14 16 18 20 22 24°:ryE ARs 
1 I I I I I I — I I I I I I ' I II I I I I ■- 




_l_l 1__LJ I I I I I I I I L_l 1,1 I I I L 



AGE (3 



10 12 14 le rs 20 22 24 YEARS 



Fig. igS. — Size and eflSciency go together (Goddard). 



interest quickly. They are not observant, are not able to dis- 
criminate quickly and accurately color, weight, form, or size. 
They may be unduly idle and listless or overexcitable. They 
are often disobedient, wilful, and liable to attacks of stubborn- 
ness and bad temper. They are untidy in their personal habits 



304 



EXERCISE IN EDUCATION AND MEDICINE 



(Fernald), awkward in their gait, movement, and attitude. 
In grasping they are either feeble or they may clutch the object 
and seem to be unable to let it go. Inco-ordination is plainly 
shown in drawing and writing, in the lack of skill and dexterity 



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-1 — I — I — \ — I — r— I — 1 — 1 — I — I — \ — I — 1 — I — 1 — I [ I I I 




120 

no 

100 
30 
80 



_L_I I L_l L_l I 1 I ' I I 1 I I I I I L_L 



AGE 6 8 10 12 14 16 IS 20 22 24 years 
Fig. iQQ.— The lower the grade of meiUal efficiency, the greater is the deficiency in height 
and weight (Goddard). 

in simple gymnastics, and in the lack of initiative and spon- 
taneity. They do not show the strength, vigor, alertness, and 
courage of normal childhood. They are undersized. 

A distinction must be made between those temporarily 
retarded from poor health or unfavorable surroundings, to 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 305 




whom a change of circumstances means the recovery of their 
place in the class, and those who are permanently subnormal. 

The feeble-minded are divided (according to Goddard) into 
those who are totally arrested before the age of three, so that 
they show the attainments of a two-year-old child or less. These 
are the idiots. Those who are so retarded that they become 
permanently arrested be- 
tween the ages of three and 
seven. These are the im- 
beciles. 

Those so retarded that 
they become arrested be- 
tween the ages of seven and 
twelve. They were formerly 
called feeble-minded, but are 
now called morons, a Greek 
word for "fool," one who is 
deficient in judgment and 
sense. 

The idiots never get into 
the public school. They are 
of too low grade. The tru- 
ant, the incorrigible, and the 
dullard may belong to any 
one of the three grades. 
The incorrigibles and dullards are sometimes temporarily sub- 
normal, but more often are morons or imbeciles. 

Any child that is not able to profit by the ordinary methods 
of instruction given to children of his own age should be con- 
sidered backward or defective, and all such cases should be care- 
fully observed, and a record of their habits and mental char- 
acteristics should be made in co-operation with the medical in- 
spector, or, if necessary, with an expert on mental conditions. 
A thorough examination should be made of the special senses 
and throat; adenoid growths where found should be removed, 
and defective vision or hearing corrected. The removal of these 



Fig. 200. — Typical adenoid face. The 
open mouth, expressionless appearance, im- 
pairment of hearing, and evil effects upon the 
general health have produced the condition 
known as aprosexia (Barnhill and Wales). 



3o6 



EXERCISE IN EDUCATION AND MEDICINE 



remediable obstructions is frequently sufficient to permit the 
backward child rapidly to regain his normal grade standing. 

Every child, then, who is more than a year behind his grade 
should be examined. Usually a sufficient reason will be found 
in some defect of sight or hearing or previous sickness; but 
I to 2 per cent, of all school children show actual feeble-minded- 
ness. While the opinion of the teacher or the evidence shown 
by retardation of grade is of value, the final diagnosis should 
be made by the Binet-Simon measuring scale for intelligence, 
because it is of the utmost value to be able to state to parents 
and friends that a fifteen-year-old child has the measurable 
intelligence of a child of five or six years. 

These tests have been revised by Dr. Henry H. Goddard"^ 
and tried out on 1547 supposedly normal children, of whom 554 
tested exactly at age; that is, they answered the questions for 
their respective ages; 329 tested one year above and 312 tested 
one year below. 

The following table shows graphically the results. 




Below 7yrs. 6yrs. Syrs 4yrj. 3yrj. 2yrs. lyr.Ata^e /yr. 2yrs. 3yrs. 4yrs Above 
Fig. 201. — Goddard's scale, showing the accuracy of the Binet-Simon test with his modifica- 
tions (from Pedagogical Seminary, June, igii, vol. xviii). 

To one familiar with statistical methods this curve amounts 

to a mathematical demonstration of their accuracy. 

^ Described by Professor Binet in the bulletin, "De La Societe Libre Pour 
I'Etude Psychologique de I'Enfant," April, 191 1. 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 307 



'^i:;^m- 



Briefly, these tests consist of a series of questions, increasing 
in difficulty with the age of the child. The questions are four 
or five in number, and include the muscular sense by having 
the child sort out blocks of wood having the same size but 
different weights. He must also copy a geometric figure, a 
sentence, count and match objects and spaces.^ 

In testing the emigrants at ElKs Island for feeble-mindedness, 
use is made of the Seguin form board (Fig. 202) and of various 
modifications of it, by such as Knox's Imbecile Test, Healy's 
Frame Test, and Knox's Moron Test, all of which require the 
putting of irregular blocks in 
their places within a definite 
time limit and so testing 
motor ability. 

It is found that a certain 
number of children in every 
school are what might be 
called motor dullards. They 
lack the average physical in- 
telligence, are clumsy and 
inefficient. They almost in- 
variably show a mental slow- 
ness or deficiency, and in- 
spection of a large number 
bring out cases of anemia, chorea, mouth breathing, and 
general nervous insufficiency, shown in speech defects, habit 
movements, and other such symptoms. Where possible, these 
pupils should be weeded out and put in special classes for 
backward children. Two such boys in a Manhattan school 
were trained in vigorous athletic work, and were thus enabled 
to raise their scholarship from zero to B plus, becoming alert, 
vigorous, self-confident, and resourceful. Similar results could 
doubtless be obtained in many others. The necessity of a 
physical examination in the discovery of defects previously un- 
known to pupil or parent is shown by the report in one high- 
^ Mental Deficiency, Henry H. Goddard, igi4. 




Fig. 



202. — The Seguin form board in use 
(Henry H. Goddard). 



3o8 EXERCISE IN EDUCATION AND MEDICINE 

school in New York, in which out of 384 boys examined 40 
per cent, required treatment. 

When a diagnosis has been made the parents should be 
frankly and tactfully taken into the teacher's confidence, the 
use of opprobrious terms to express the mental defectiveness 
being carefully avoided. The parents should be impressed with 
the fact that the child is not doing well at school, and that for 
his own sake he should have special attention to prevent him 
from going backward as well as to train such powers as he has. 

In Detroit it is the custom, after the Binet-Simon test has 
been used and the child found backward, to send a notice to the 
parents asking them to consult their family physician concern- 
ing the child. If no result follows, the principal calls upon the 
school physician to give the child an examination for remediable 
defects. This examination is reported to the parent. If the 
parent is unable to provide proper medical attention, the princi- 
pal reports the case to the Child Study Committee and a special- 
ist is called in. The parent is then consulted by the principal, 
and questions regarding ancestry and peculiarities are discussed 
and a report sent to the Child Study Committee, who either 
exclude the child or put him in special classes. 

Unless retardation is sufficient to require treatment and 
protection in an institutioh for the purpose, cases of backward- 
ness may be taught in classes composed of children who show 
about the same degree of mental deficiency. They should, hov/- 
ever, be put in a special room or, where possible, in special 
schools. In this way the low-grade children are prevented 
from interfering with the regular work of the class. They are 
given the advantage of some educational training, combined 
with a large amount of manual and physical work selected with 
the view to provide them with some means of livelihood later 
on. Very little can be required of them in purely intellectual 
work, and their life is made miserable by trying to teach them 
something which is beyond their mental capacity and which 
can only put them at a disadvantage before their comrades. 

Their physical education would vary with the degree of the 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 309 

defect. In a school system special classes should be provided 
for them, and teachers should be specially prepared to take charge 
of these atypical pupils. Public schools for them have been in 
successful operation in Germany, Norway, Sweden, Denmark, 
France, Switzerland, and England. In London alone there 
are more than sixty classes, and such classes are also in suc- 
cessful operation in Philadelphia, Providence, Boston, Chicago, 
and elsewhere. 

Backward children are segregated for their own benefit, and 
also for the benefit of the other pupils of the school whom they 
would hold back. The classes should be small, not over fifteen 
in number, and great attention should be paid to improving the 
child's surroundings in the home as well. His physical condi- 
tion should be kept as favorable as possible by nourishing food, 
regular outdoor exercise, bathing, ample sleep, and careful 
attention to bodily functions and habits. The mental awaken- 
ing resulting from an improved state of nutrition and bodily 
vigor alone is often striking. The education of the special senses 
and the training of the voluntary muscles to prompt and accu- 
rate response must precede and prepare the way for the more 
purely intellectual training. The unseeing eye, the unhearing 
ear, and the other obstructed avenues of approach to the central 
intelligence must be opened up by a series of carefully arranged 
sensorial gymnastics. 

The ultimate aim of these exercises is to train the child 
to acquire knowledge from his sensations. Next in impor- 
tance comes the discipline of the muscles, not only for mus- 
cular growth and practical co-ordination, but to strengthen 
the well-recognized relationship of thought to muscular move- 
ment, motor training being one of the most potent factors to 
arouse the feeble powers of voluntary attention, observation, 
and comprehension. This motor education should begin with 
the common games and occupations of normal childhood. The 
child should be taught to throw and catch a ball, to kick a foot- 
ball, to jump and run, and, in fact, to perform larger move- 
ments calling for the natural use of the various muscle groups, 



3IO 



EXERCISE IN EDUCATION AND MEDICINE 



progressing with an eye to the normal evolution of the play 
instinct, as described in the chapter on Age, Sex, and Occupation. 
Music and rhythmic marching are preferable to more formal 
gymnastics involving close and continued attention, prompt 
obedience, and accurate motor response. Mentally deficient 
children frequently show a more acute feeling for rhythm than 
the normal child. Music holds their attention, and they respond 
quickly to such rhythmic exercises as those of Dalcroze, which 
might well be employed in their education. These qualities 
must be cultivated by the simplest movements or the good effect 




Fig. 203. — Crippled and defective children gardening (Playgrounds Association of Phila- 
delphia) . 



still be lost. Gymnastics by commands are at first entirely be- 
yond most of these children, whose attention quickly lags and 
whose co-operation and interest it is impossible to maintain. 

What has been said of general motor training applies with 
special force to the training'of the finer co-ordinations of hand 
and forearm. This can best be done by kindergarten methods 
and by manual occupations, such as Sloyd^ basketry, and weav- 
ing. Indeed, there are no other means of influencing so pro- 
foundly the mental growth of the defective. Instruction must 
always begin on a very low plane, and progress at best will 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 31I 

be slower than in the normal child. At an early age much of 
this neuromuscular training by gymnastics may be directed 
to the various handicrafts and simple manual labor, which will 
enable many of these children, especially in institutions, to be- 
come self-supporting in after-life who would otherwise become 
a burden on the community. Under this course of education 
some children develop up to the grade classes and return to 
them, completing a fairly satisfactory school course. When, 
however, the degree is extreme, and the condition is congenital 
or the result of disease or injury, these brain abnormalities re- 
main permanent, and no really feeble-minded person ever was or 
can be entirely cured (Fernald). 

It is always a question of how much improvement is possible 
in each individual case. Many of them may be trained to be at 
least self-supporting if not self-controlling, but the greater num- 
ber need oversight and supervision as long as they live. A large 
proportion become public charges, and it is important that they 
be kept in institutions as they approach adult life that they 
may not have an opportunity to yield to the physical tempta- 
tions to which they are so peculiarly susceptible and so propa- 
gate their own kind. Cases of gross defect are always better 
treated in institutions than at the school or in their own homes, 
but even in aggravated cases much can be done by motor train- 
ing to improve their bodily habits and to increase their range 
of usefulness, making them more observant and appreciative 
of their surroundings. According to Barr's experience,^ the best 
results are obtained from military drill, games, and gymnastics, 
with manual training varying in difficulty with the grade of 
backwardness, the relationship of the grades in mental defect- 
ives being somewhat like the successive ages in children so far 
as their helplessness is concerned. The lower grades are like 
the youngest children, but their physical conformation does not 
correspond with their mental backwardness. 

The more educational movements should be directed, first, 
to the posture and gait of the patients. Their most charac- 
^ Mental Defectives, Martin W. Barr (Blakiston & Sons). 



312 EXERCISE IN EDUCATION AND MEDICINE 

teristic defect is the shambling walk, with dragging feet and 
slouching figure. This may be corrected by running to command 
up or down hill, by walking contests on tiptoe indoors or out- 
doors. Such exercises briskly carried out awaken the atten- 
tion and make a good break in a long occupation period. The 
use of a springboard supplementing walking drills develops 
elasticity in the dragging step. Stooping may be corrected by 
balancing a book or basket on the head and the poise and ease 
of bearing thus improved. The placing of a ladder horizontally 
on the floor is a valuable way of correcting a slouching gait. 
The child steps between the rounds and must raise the foot well 
at every step. The stepping on bricks placed at regular dis- 
tances is another device for the same purpose. 

Military drill has a peculiar educational value for a defect- 
ive. The boy learns a certain standard of precision, atten- 
tion, and readiness of movement. The emulation brought about 
in these movements is important. The stimulation of his am- 
bition to attain, to the power of the others, to present arms in 
order that he may not disturb the general niovement of the squads, 
is alone one of the most important means of character building. 

This disciphne is also obtained by g>Tnnastic exercises in 
which prompt obedience to command is insisted upon. These 
drills should be practised only for a few minutes at a time, and 
varied in difficulty to suit the grade of the class. The training 
for skill and co-ordination of the arms and hands (Fig. 204) may 
be accomplished by the horizontal and parallel bars and the use 
of ladders for climbing. 

One of the most defective co-ordinations in the at}'pical child 
is found in the power of grasping. The weak and nervous fingers 
of the untrained imbecile can retain nothing within its grasp, or 
the nervous clutch, unconscious of its violence, is equally ex- 
pressive of mental incapacity. 

It is necessary, then, to train this co-ordination by simple 
and strong exercises of hanging and climbing, catching and 
throwing, before giving to the child a hammer, a saw, or a chisel. 
The throwing and catching of balls, from the baseball to the 



PHYSICAL EDUCATION Or MENTAL AND MORAL DEFECTIVES 313 

medicine ball, are useful, as are the simpler exercises on the 
bars and rings. 

In high-grade defectives this power of regulating the grasp 
is better controlled, but it may be still further trained by weav- 
ing, club-swinging, or blackboard drawing with both hands, after 
the system of J. Liberty Tadd. 

Active sports are to be warmly encouraged, the exhilaration 
to the onlookers as well as to the participants being a good anti- 
dote to the lethargy and the timidity of the feeble-minded. The 




Fig. 204. — Defective class. Nine to fifteen years. First grade work. Sideward bending, 
sfiowing the poor co-ordination in the carriage of the head and arms (Krogh). 



circulation is stimulated thereby, and the muscles, which are 
inclined to be flabby and cold, are improved in nutrition. 

Dancing is an amusement in which most of these children 
delight, and many excel, and its good effect is evident at once. 
Running, racing, swimming, leaping, vaulting, quoits, tennis, 
croquet, are all most suitable, while football, baseball, and basket- 
ball are frequently well played and eagerly discussed by children 
even of a very low grade, but lack of initiative is the outstanding 
characteristic of the great mass of incapables. 

During a recent visit to an institution for the feeble-minded 



314 EXERCISE IN EDUCATION AND MEDICINE 

a group of boys were seen working in the field. Their attention 
being attracted, they all stopped, some with bent back about 
to lift a shovelful of earth, others in various stages of arrested 
movement. Thus they remained until called back to their 
work by the shout of the foreman. This mental apathy ex- 
pressed by sluggish physical movement is present in nearly 
all low grades of intelligence, and can only be reached by such 
means as have been described. 

The other type of mental defectives shows an abnormal 
excitability, seen in restlessness, insubordination, and truancy, 
and it is these children that so frequently find their way into 
the Juvenile Court, the reformatory, and the jail. 

Blunted intellect and moral failure, as a rule, go hand in 
hand, and it is a mistake to suppose that the criminal child or 
man is naturally bright. If apparently bright, it is usually in a 
narrow line and self-repeating — more allied to animal cunning 
than to intellectual power. He is vacillating, without fixed 
purpose or aim, incapable of pursuing a consistent plan, and of a 
rudimentary or atypical mental development. 

Physical training, then, is specially indicated in the case 
of the youthful dehnquent who so often enters the school 
poorly nourished, anemic, with muscles soft and flabby, from 
a life passed in the dark and unsanitary tenement house, home- 
less on the street, or uncared for in the village. Along with 
this common city type there will also be found in the Juvenile 
Court or special training-school the apathetic dullard, stupid 
and shambling, whose every motion expresses mental lethargy 
and physical incapacity. As a rule, these cases detest exercise 
or anything that disturbs their stupor, and for them discipline 
must be Spartan in character, for exercises need not be agree- 
able to be beneficial, as has been well insisted upon by Sar- 
gent and is daily proved in the reformatories. 

A course of physical training for such children acts bene- 
ficially in three ways: By awakening the brain activity of those 
who are mentally defective; by bettering the badly nourished and 
flabby muscular system by developing the heart and lung power; 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 315 

and by demanding alert and prompt response to command, a 
most. important lesson, to be taught so well in no other way. 

The course of training for the incorrigible youth or young 
criminal would begin with mihtary drill, in which the boys are 
formed into companies with sub-ofhcers selected from their own 
number. These companies are taught the usual evolutions of 
marching, countermarching, and the manual of arms. The 
authority of the oihcers selected from among the boys should 
cease with the end of each drill, and promotions should be made 
with the greatest care. There is always a temptation to bully 
if the giving of this temporary authority is not rigidly guarded. 
The perfection to which the military drill can be carried is shown 
by the attainment of the boys in the industrial school at Glen 
Mills, whose evolutions on the field would do credit to regular 
soldiers. 

The second means of training is by gymnastic exercises, and 
those in use at Glen Mills are semimilitary and founded on the 
German plan, rather than the Swedish. The boys are lined up 
and marched to the gymnasium, which has a concrete floor. 
Coats, hats, shoes, and stockings are removed, and a brisk drill 
is given either with wands or dumb-bells. This is followed by a 
five-minute period of free play, in which the noise of the boys is 
in marked contrast to the comparative silence of the class work. 
Following this is apparatus work on the parallels, horse, and 
horizontal bar, class leaders being promoted from among the 
boys. After another period of free play the lesson ends by gym- 
nastic games. The boys are then lined up, shoes and stockings 
are put on, and they are marched back to their various occupa- 
tions. 

The third means of training is by outdoor sports and games, 
in which great freedom of organization and conduct is allowed, 
although strict supervision is still kept and the boys are pun- 
ished for misbehavior by being made to stand along the side 
hne of the playground with the back to it for periods of five or 
ten minutes. If the offense is a severe one, the salutory exercise 
of continuous, slow, deep knee-bending is added during their 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 317 

period of punishment. Competitive games with outside insti- 
tutions are arranged, and track and field sports are freely in- 
dulged in, giving good opportunities for moral and ethical train- 
ing, which are not neglected. The results have been so satisfac- 
tory that physical training is now established on an equal foot- 
ing with industrial training and the school of letters in the regu- 
lar days' curriculum of these incorrigible boys. 

Physical training has a marked effect on the physique, 
mentality, and conduct of criminals who have attained their 
full growth, as proved by the experiments of Hamilton D. Wey, 
at the Elmira State Penitentiary. His description of the criminal 
is illuminating: 

''The average youthful criminal, as encountered in the 
prisons of the State, is an abnormal production, physically, 
mentally, and morally. Generally under weight, with repulsive 
features in some one or more lines, and asymmetric head; he is 
coarse in fiber and heavy in his movements. His mind, while 
not diseased, is undeveloped, or it may be abnormally developed 
in certain directions, the smartness resulting therefrom partak- 
ing of low cunning and centering about self. He is deficient in 
stability and will-power, and incapable of prolonged mental 
effort and application. His intellect travels in a rut and fails 
him in an emergency. His moral nature shares in the imper- 
fections of his physical and mental state. He does not possess 
the power to discriminate between right and wrong, or if so, it is 
in favor of himself and avails nothing to society. It is easier for 
him to incHne to evil rather than to good, to the animal rather 
than to the intellectual, and in this he is true to himself. His 
is a perverted moral nature — a blunted mind and a crude body." 

It is to physical training that we must look for the awak- 
ening of those powers that can be directed by firm discipline to 
the physical, mental, and moral betterment of these derelicts. 

During a period of sixteen months a class of 43 dullards was 
given a course of physical training at Elmira. This comprised 
baths at frequent intervals, in conjunction with passive exer- 
cise, kneading the muscles, working the joints, and general 



3l8 EXERCISE IN EDUCATION AND MEDICINE 

friction by a professional trainer; and a manual drill in caHs- 
thenics to supplement the shop work, from which they were 
excused, although their school work was taken as usual. They 
were put on a specially nourishing diet. The physical exercise 
lasted for about two hours a day. They began with the ordinary 
marching, and in time were taught other evolutions, although it 
was a matter of weeks to teach them to keep step. When they 
could do this well, they were given setting-up movements and 
exercises with dumb-bells up to three pounds in weight. The 
first experiment lasted from June until November, and showed 
a net average gain of 1.23 pounds a man. Various skin diseases 
disappeared, the muscular condition and the carriage improved, 
and the response to command became much more rapid and 
accurate. The whole expression of the face improved, the dull, 
stolid look assumed a more intelligent expression, and the eye 
gained in brightness and vivacity. 

A mental awakening accompanied this, and their progress 
in school rapidly showed the effects. During the five months 
they were under observation their average marking in school 
was 74.16 per cent., as against 45.2 per cent, for five months im- 
mediately preceding their course of special training. 

This improvement was continued to a remarkable degree, and 
the stimulation of the physical powers in the case of three of the 
class impressed their mental organization to such a degree that 
it enabled them to earn their release on parole, whereas if left 
to themselves their minds would never have been so quickened. 

To train these dullard's legs and arms to act with precision 
and in unison was more than the mere rehearsal of mechanical 
movements. It was mental as well as physical training, and 
Dr. Wey is of the opinion that in the prisons and reformatories 
of the country "there is a class of youthful felons who can thus 
be reached in their growth period and improved primarily 
through the training of the body, the cultivation of the head 
following in good time. If penal institutions in their educational 
work could more often look upon bodily training as a powerful 
agent for the physical, mental, and moral reformation of their 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 319 

charges, more men would be released at the expiration of their 
time competent to maintain themselves honestly." 

This result is only to be obtained by careful physical train- 
ing with an educational purpose, for, as F. H. Nibecker, the 
superintendent of Glen Mills School, so well puts it, "Hard work 
of any particular kind is not complete exercise, nor is it equiva- 
lent to physical training, by which the perception is quickened 
and mental training results, quite as pronounced in effect as 
from efforts that have mental training more directly in view." 



PART II 

EXERCISE IN MEDICINE 



CHAPTER XVIII 



THE APPLICATION OF EXERCISE TO PATHOLOGIC 
CONDITIONS 

The efficacy of both active and passive exercises in the 
treatment of pathologic conditions depends on their power 
to change anatomic structure and to stimulate physiologic 
function. This anatomic and physiologic effect is very differ- 
ently expressed in exploits of endurance, in feats of strength 
or skill, and in the passive procedures of manipulation and 
massage. 

Exercises of strength requiring little co-ordination rapidly 
add to the bulk of the muscle tissue, but in exercises of skill 
the nervous system receives accurate training while the muscle 
girth is increased but slightly. Contrasted to them, mild auto- 
matic exercises of endurance train the heart and expand the 
lungs more surely than do either supreme efforts of strength 
or the cultivation of skilful muscular control. 

Passive exercise has a purely mechanical effect on the mus- 
cle tissue and circulation which is obtained without that mental 
concentration required to educate or re-educate atrophied and 
undeveloped co-ordinations, and without taxing the heart and 
lungs. By it the nutrition of a part is maintained or improved 
through its blood-supply alone. 

The use of exercise has had an important share in the treat- 
ment of disease since Hippocrates used it at the sanatorium at 
320 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 32 1 

Cos, and Galen advocated it in words that are as true now as 
they were eighteen hundred years ago, but it is Ling and his 
successors,^ Brandt, HarteHus, Kleen, Wide, Kellgren, Cyriax, 
and Graham, who have done the most to bring it to its proper 
place as one of the valuable means in the modern treatment of 
disease. 

Exercises of strength require maximum contractions. They 
alternately contract and relax a muscle, squeezing out the blood 
and waste material and allowing the muscle to fill again. They 
require great concentration of attention, and in consequence 
are of especial value for weakened or undeveloped muscle 
groups. It is on exercises of this class that we depend for de- 
velopment of the weakened and inactive muscles of the ab- 
domen, which yield to the pressure of the viscera and permit 
distention of the abdomen and certain forms of hernia. It is 
to this class of exercises that we turn to develop the muscles of 
the chest, back, abdomen, and legs in that large group of de- 
formities which result from yielding of the structures of support 
at the foot, hips, back, and neck; in paralysis these simple concen- 
trated movements of carefully selected groups are the chief hope 
for a continuance of a partial recovery of lost power. They are 
of value in the general development of parts put into disuse by 
more grave surgical necessity, and can do much to shorten 
postoperative convalescence. Their value after appendectomy 
has been interestingly shown by Dr. Eugene H. Pool, in the 
report of his own case, in which he began simple free move- 
ments on the third day after the operation. He practised them 
three times a day, was out of bed on the eighth day, and ex- 
perienced so little fatigue that on the thirteenth and fourteenth 
days he was able to cover 60 miles over a rough trail by wagon 
and on horseback with no ill effects. His patients have been 
unanimous in showing shorter convalescence, feeling better from 
the very beginning of the exercises. The movements he used 
are typical exercises of strength reduced to their simplest form, 
as seen in the following list: 

^ See Bibliographia Gymnastica Medica, E. F. Cyriax. 



%,22 EXERCISE IN EDUCATION AND MEDICINE 

(i) Ankles flexed and extended. 

(2) Lower extremities rotated separately. 

(3) Hips flexed and extended. 

(4) Knee flexed and extended. 

Nos. 3 and 4 to be used with caution and sometimes restricted to 
one side onl}', and omitted on the right side after a right hernia 
or appendectomy. 

(5) Fingers flexed and extended. 

(6) Wrists flexed and extended. 

{7) Forearms pronated and supinated. 

(8) Forearms flexed or extended. ■• 

(9) Arms flexed and extended. 

(10) Neck flexed \>y raising head. 

(11) Neck flexed from side to side. 

(12) Deep breathing. 

Each exercise to be done ten times, increasing up to twenty- 
three times, and repeated three times a day. They should never 
be continued beyond the point of moderate fatigue, and some 
of them should be given with resistance. By this means the cir- 
culation is improved, muscular weakness and atrophy diminished, 
and the return to normal made more rapid than after the usual 
procedure of absolute inaction. They may well be supplemented 
by massage and manipulation. 

This is merely one example of the employment of exercises 
of strength in pathologic conditions, and many more will be 
cited in the detailed account of the treatment of such special 
conditions as diseases of the heart. 

In order that prescriptions of exercises may be made intel- 
ligible it is necessary that the various positions and movements 
be named and defined, for only in this way will it be possible to 
write uniform prescriptions that can be readily carried out by an 
attendant when it is not possible for the surgeon to administer 
them himself. 

The fundamental positions of the body are jive in number — 
standing, sitting, lying, kneeling, and hanging. 

In standing (Fig. 206), the patient stands with the heels 
together, feet at 60 degrees, and knees straight, trunk erect, 
chest well arched forward, head erect, and chin drawn in. 
The arms straight and the hands at the side, palms in. 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 323 



In the sitting position (Fig. 207) the head, neck, and chest are 
as described above, the buttocks and thighs resting on the hori- 
zontal seat, feet on the ground or on some other support, legs 

close together, arms hanging 
V¥/ freely downward. 

In the lying position (Fig. 
208) the patient rests on a 
horizontal couch supine, arms 
at sides as before. 






Fig. 206. — Standing. Fig. 207. — Sitting. Fig. 208. — Lying. 

In the kneeling position (Fig. 209) the position is the same 
for the head, trunk, and arms. The knees are bent at right 
angles and the weight rests upon the 
legs, the feet being extended. 

In the hanging position (Fig. 210) 
a bar above the head is grasped by the 
hands divided by the breadth of the 





Fig. 209.— Kneeling. Fig. 210.— Hanging. 

shoulders. The weight is carried by them, and the rest of the body 
is as in the standing position, except that the feet are extended. 

The derived positions of the arms are: 

(i) Hips firm — the hands placed upon the hips with the 
thumbs directed downward (Fig. 211). 



324 



EXERCISE IN EDUCATION AND MEDICINE 



(2) Be7id standing — forearms in, extreme flexion and supina- 
tion (Fig. 212). 






Fig. 211. — -Standing; hips firm. Fig. 212. — Bend standing. Fig. 213. — Swim sitting. 

(3) Swim standing — the arms placed in front of the chest, 
elbows at the height of the shoulders, forearms in extreme flexion, 
palms directed downward (Fig. 213). 

(4) Yard standing — arms stretched outward horizontal, 
pahns downward (Fig. 214). 






Fig. 214. — Yard standing. 



Fig. 215. — Heave sitting. Fig. 216. — Stretch-stride 

standing. 



(5) Heave standing — upper arms stretched horizontally out- 
ward, elbows fixed at a right angle and directed upward (Fig. 215). 

(6) Stretch standing — arms stretched vertically upward, 
palms in (Fig. 216). 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 325 



(7) Neck firm — elbows raised and carried backward, hands 
touching behind the head, pahns forward (Fig. 217). 






Fig. 217. — Neck firm. Fig. 218. — Knee-bend toe standing. Fig. 2ig. — Walk standing. 

The derived movements of the legs are: 
(i) Toe standing — raising heels. 

(2) Knee-bend standing — bending the knees to a right angle 
(Fig. 218). 

(3) Walk standing — one foot placed two foot-lengths directly 
forward, the weight carried upon both feet evenly (Fig. 219). 





Fig. 220. — Stretch-stride standing, side bending. Fig. 221. — Fall-out standing. 

(4) Stride standing — feet placed two foot-lengths apart (Fig. 
220). 

(5) Fall-out standing — the body lunged forward three foot 
lengths, the anterior knee bent until over the toe-tips, the other 



326 



EXERCISE IN EDUCATION AND MEDICINE 



leg kept in full extension, and the toe carried forward and out- 
ward above the bent knee, the corresponding arm stretched 
forward, upward, and outward. The arm, trunk, and extended 
leg lie in the same plane, the downward stretched arm parallel 
with the upper arm (Fig. 221). 

Positions obtained by moving the trunk are: 

(i) Arch standing — the spinal column overextended. 

(2) Side bending — the trunk flexed laterally (Fig. 220). 

(3) Turn standing — trunk rotated to one side without moving 
the hips. 

(4) Stoop standing — trunk flexed at hip-joints, legs straight. 

All these movements of the arms 
and trunk may be obtained in the sit- 
ting position. In addition, a ride sit- 
ting is taken by sitting astride a couch 
, or chair with the feet fixed (Fig. 222). 





Fig. 222. — Ride sitting. 



Fig. 223. — Sit lying. 



Long sitting — the patient rests with the legs supported throughout 
their entire length. Sit lying — the head, trunk, and thighs are 
horizontal, the knees and legs hanging over the end of the couch 

(Fig. 223). Half -sitting — the pa- 
tient stands on one leg which carries 
the weight of the body, the rest of 
the body being in the sitting posi- 
tion. Spring sitting — the patient in 
the fall-out standing position, with 
the thigh and buttock of the forward 
Fig. 224.-Spring sitting. ^eg Supported on a chair (Fig. 224). 

The same movements may be obtained in the lying position, 
and in addition: 




APPLICATION OP EXERCISE TO PATHOLOGIC CONDITIONS 327 

(i) Crook lying — the patient's knees drawn up with the heels 
resting upon the couch (Fig. 225). 

(2) Forward lying — the patient prone and the weight sup- 
ported by the forearms. 

(3) Side lying — the patient lying on one side, the head sup- 
ported by the bent raised arm on the underside. 

(4) Leg lying — forward or side, the patient lying over the 
end of the couch from the hips up (Fig. 226). 

By raising part of the couch the body may be raised into 
the half -lying position (Fig. 227). 





Fig. 225. — Crook half-lying. Fig. 226. — Leg lying. Fig. 227. — Heave 

hanging. 

The characteristic derivative position from hanging is the 
heave hanging, in which the weight is pulled up until the upper 
arms are horizontal (Fig. 227). 

From these fundamental and derivative positions practially 
any combination can be made, but there are many movements 
and positions in gymnastics and games that are so compHcated 
that they pass beyond the compass of this chapter. 

Exercises of skill enter into the treatment of disease, espe- 
cially in the re-education of co-ordinations that must be learned 
for the first time or that have been impaired or lost by disease. 

Many children have never learned the proper standing pos- 
ture, and must be educated to maintain it with the least strain 
to muscles and ligaments. Others have lost it through conditions 



328 EXERCISE IN EDUCATION AND MEDICINE 

beyond their control — in the school or factory — and the long 
train of symptoms in the feet, legs, back, chest, and neck are to 
be met in great part by re-education. The relaxed abdomen 
must be put in proper relation to the thorax if ptosis of the 
abdominal organs is to be avoided, and this is best accomplished 
by exercises of skill in which the trick of correct standing is taught 
and impressed on the growing child. 

In paralysis exercises of skill come in to supplement the 
more purely mechanical contraction and relaxation of the muscle 
groups, and in many of the neuroses, like stammering, chorea, 
and tic, the only treatment available is the slow and systematic 
re-education of the complicated co-ordinations that have become 
disordered or lost through disease. In tabes dorsalis this train- 
ing in skill is our only available treatment for the ataxic gait, 
and here its value has had a triumphant demonstration in a 
field in which the neurologist is too often content with a hair- 
splitting diagnosis as the ultimate aim of his efforts. 

It is in this class of cases that many of the games and sports 
described in previous chapters have a value that is hard to over- 
estimate. Judgment of speed, distance, weight, and force can 
be cultivated by the various games with light and heavy balls 
better than in any other way, and they enter largely into the 
treatment of many conditions, while the power of rhythm over 
disordered co-ordination has always been gladly used by all 
mtelligent physicians. 

Exercies of endurance have another field to fill. Their 
influence on muscular development, on skill and nerve train- 
ing, is quite overshadowed by their general tonic effect, and by 
the profound influence they exert on the respiration, circula- 
tion, and excretion. The value of walking and hill-climbing is 
primarily on the heart and lungs. For this reason Oertel devised 
his walking cure for diseases of the heart, realizing that what- 
ever may be the anatomic condition of a heart, if it can be 
trained to do its normal work it becomes to that extent function- 
ally sound. Hence, his gradual development of heart and res- 
piratory power, and the reduction of encumbering fat burned 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 329 

off in the slow fire of comparatively mild but long-continued 
muscular action. 

It is to exercise of endurance, like walking, climbing, and 
riding, that the gouty or diabetic patient must turn for relief. 

GOUT 

Like obesity, with which it is so often associated, gout is 
usually a disease of overnutrition and underelimination, and 
the indications would be to decrease the intake and increase the 
output of waste by all the avenues. 

The rules for diet are still the subject of dispute, but all 
writers agree that exercise is of great value in reducing the 
weight of the gouty patient when obese and of increasing the 
activity of the skin and lungs. The great majority of patients 
will require exercises of endurance Uke walking regulated in 
distance and speed. Golf has a peculiar value from the fascina- 
tion it possesses for individuals of all ages, a point not to be lost 
sight of in the management of self-indulgent cases. Horseback 
riding has the added advantage of vigorous massage, especially 
if the horse be trotted, and if the ravenous appetite resulting from 
the open-air exercise be kept within the limits of discretion. 
In young and vigorous subjects almost any of the active athletic 
sports appropriate to their age may be engaged in. These are 
enumerated in the table of sports and games in Chapter VIII. 
It must not be forgotten that a debauch of exercise in a vale- 
tudinarian may precipitate an acute attack by suddenly throw- 
ing the fatigue products into the circulation and causing an 
acute poisoning, so that great care should be observed to begin 
gradually and increase the amount as the system accommodates 
itself to more active exertion. 

DIABETES 

In the hygienic treatment of diabetes, exercises of endur- 
ance have an important place, since muscular action favors the 
combustion of sugar from whatever source it may be derived. 
When present, constipation should be corrected by local and 



33© EXERCISE IN EDUCATION AND MEDICINE 

general massage daily, and by the simpler forms of free or 
duplicate movements. Professor Finkler, of Bonn/ tried general 
muscle kneading in fourteen diabetics daily, a twenty-minute 
treatment being given at first, afterward increased to twice a 
day. They remained on a mixed diet. There was a constant 
diminution of urine, decrease of thirst, increase of body weight, 
and return of perspiration. When the patient is sufficiently 
strong he should be made to live as much as possible out of doors 
in a dry, warm climate, and a daily task should be set for him. 
The exercise should be gentle in character and carried out sys- 
tematically. Gardening and walking, golf or tennis, should be 
the forms selected, but the patient should be warned to stop 
within the limits of fatigue. 

A course can be carried on. to the best advantage in a sana- 
torium, with conveniences for bathing, massage, and exercise, 
where the habits of life can be regulated with greater hope of 
success. 

Suitable cases of pulmonary tuberculosis can have their 
metabolism quickened and their nutrition improved by such 
Kght exercises as have been just described, and the general tonic 
effect can be regulated with great nicety and accuracy. 

The simple free or resistive exercises of strength already 
referred to are combined so frequently with massage that to- 
gether they are frequently referred to as the Swedish movements, 
and it remains only to describe. 

Passive movements which include massage and manipula- 
tion, whose effects are nutritive on the muscle substance through 
the stimulation of the local circulation. Any conditions that 
would be improved by a heightened local circulation would 
be benefited by this form of exercise. The stimulation of the 
peripheral nerves up to the point of anesthesia is another out- 
standing effect, but the detailed action of the separate manipula- 
tions must be reserved for the next chapter. The power of mas- 
sage over the blood-supply of muscles gives it a peculiar value in 
infantile paralysis, where the circulation is slowed and the parts 
^ Schmidt's Jahrbiicher, Bd. 213, p. 218. 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 33 1 

affected are undernourished, while in a sprained or disabled 
joint, where the circulation is also subnormal and the process 
of repair is delayed on account of the enforced immobility 
of a structure whose natural function is movement, massage 
is the most valuable and widely used means of hastening 
recovery, 

SPRAINS 

The swelling and tension that follow a sprain can be quickly 
absorbed by gentle and careful massage, accompanied by elastic 
pressure with the application of heat between the treatments. 
The tension disappears as the fluid is carried off, the tempera- 
ture falls, and the pain caused by pressure on the sensory nerves 
is relieved. Extravasated blood is broken up, and can be seen as 
discoloration following the Hnes of the lymphatics ; the adhesions 
usually found between torn and mangled surfaces are prevented, 
although time is always needed to firmly repair structures that 
have been actually lacerated. 

If the sprain be recent adhesions are prevented altogether, 
but if they have already formed they may thus be stretched 
slowly and gradually by repeated gentle movements, or may be 
actually torn, with instantaneous relief to the patient. It is 
in these manipulations that bone-setters have acquired their 
reputation for supernatural skill, many miraculous instances 
being recorded of the immediate recovery of long-disabled joints. 
After perfect freedom of movement has been obtained, the 
voluntary power is sometimes slow in returning, and the recov- 
ery must be completed by active voluntary exercise in accord- 
ance with the natural movements of the joint. 

In older cases, where the synovial membranes have lost their 
resiliency from long-continued distention, where the tissues are 
sodden and edematous and the effusion dense and firm, massage 
can be used with greater freedom to disperse the chronic conges- 
tion and raise the tone of the tissues. This improvement is 
often surprising in its rapidity. The joint that has remained 
for weeks cold and inactive, incapable of performing its proper 
movements, the seat of constant wearing pain, recovers its 



332 EXERCISE IN EDUCATION AND MEDICINE 

flexibility, loses its pain, and allows itself to be handled and used 
with freedom. Manipulating the joint, moving it throughout 
the greatest extent of its normal range, should be added to mas- 
sage in recent cases as well as those of long standing. These 
movements stretch or snap small adhesions that limit the excur- 
sion of the joint or press upon nerve-endings, causing acute pain. 
Few minor operations give such instantaneous and striking relief 
when used with care and judgment. 

In an old sprain the tissues are matted together; the surface 
of the skin is dry and harsh, bluish, Kvid, and shrunken in 
appearance. The stagnant blood circulating slowly through 
the obstructed and narrowed vessels is unable to give the tissues 
sufficient nutrition or to remove the accumulated debris of a 
month's inaction. Manipulation and massage act upon the 
muscles, nerves, blood-vessels, and skin, and the circulation at 
once renews its power. With the application of friction and 
kneading the life of the part is quickened, the veins and ab- 
sorbents are emptied first, and the fluid contained is driven on 
toward the heart; the pressure falls in the smaller vessels and 
tiny irregular lymph-spaces, extending through the tissues in 
all directions. Their contents are driven into the emptied 
vems. The circulation becomes more rapid. Metabolism 
is carried on with greater energy. The tissues become full and 
sensitive to the touch, and the parts regain the even and rounded 
contour of active health. The skin loses its harshness, becoming 
soft and pliable, and after a single apphcation the muscles are 
capable of working with less fatigue, while the joints become 
pliant and the Hgaments relaxed. Adhesions are permanently 
stretched or broken down and the encumbering waste mate- 
rials thrown into the circulation, while the effect upon the ner- 
vous system is indicated by the disappearance of the pain and 
sense of insecurity. 

Dr. W. H. Broad reports rapid recovery of knee injuries 
with effusion by massage beginning on the third day, and ac- 
companied by movement, increasing daily with pressure in the 
intervals of active treatment. 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 333 

In the same way massage is used to quicken the mending of 
fractures; the spHnt being removed, the part gently massaged 
and a slowly increasing dose of movement administered, the 
splint being placed again in position. ^ 

In the general inactivity required by the rest-cure of Weir 

Mitchell massage has taken its place as a necessary part of the 

triple treatment, the other agents being rest and overfeeding, 

and it may be said thus to correspond to the other postoperative 

exercises. 

RHEUMATISM 

Among the most prominent diseases for which passive move- 
ment, massage, and vibration can be used is rheumatism, in some 
of its myriad forms. 

The manifestations of rheumatism, whether they appear 
in the muscles or in the joints, may often be treated by vibra- 
tion and massage with every considerable success. 

In muscular rheumatism the sternomastoid, the erector spinge 
muscles, and the lumbar fascia are favorite sites for the attack. 
There is probably a coagulation of the semifluid muscular sub- 
stance, with adhesions and retention of waste products, of which 
uric acid is the worst, causing pressure upon and irritation of the 
nerve filaments and spasm of the muscles. The pain of this condi- 
tion is exceedingly severe and requires rest and counter-irritation. 
Vibration may be applied to inhibit the pain by using the ball at- 
tachment (Fig. 242, 3), a medium stroke, and deep pressure sev- 
eral times a day over the spinal centers governing these parts, and 
the soft brush and rapid stroke over the affected parts them- 
selves several times a day if the pain is acute. Massage is also 
useful after the acuteness has abated in soothing the irritation 
by gentle stroking and friction, increasing in force with the im- 
proved toleration of the subject. The evils resulting from forced 
inaction in patients who are suffering from muscular rheuma- 
tism, either in the lumbar region or elsewhere, is also counter- 

1 See Dr. Lucas Championiere, Traitement Des Fractures par le massage et la 
mobilization; James B. Mennell, Treatment of Fractures by Mobilization and 
Rest; Sir Wm. H. Bennett, Massage in Recent Fractures. 



334 EXERCISE IN EDUCATION AND MEDICINE 

balanced by general massage. The movements used vary 
from gentle stroking to deep kneading of the muscle masses, 
with manipulation of the stiffened joints. 

Arthritis deformans is an incurable disease, but the inevitable 
progress of deformity can be held back, and great comfort can 
be given to the patient by vibration, massage, and manipula- 
tions. Ankylosis may be prevented by checking the formation 
of adhesions and the stretching and breaking down of those 
already formed, while atrophy of the muscles, always a pro- 
nounced symptom, may be delayed. 

Douglas Graham reports most encouraging results in a num- 
ber of cases treated by himself, five out of six showing marked 
improvement. His mode of procedure was deep manipulation 
without friction, passive motion as far as the pain would allow, 
and sometimes farther, and resistive movements as soon as they 
could be done. He disregards pain if it rapidly disappears after 
the treatment. If it persists, treatment must be suspended. 
He recommends kneading with one hand to break up indurations 
or disperse effusions, while the other pushes along the circulation 
in the veins and lymphatics above the joint. Massage would 
not be used, of course, when the disease is very active.^ 

The power of massage to stimulate or anesthetize nerves, 
and to act on the reflexes, is such that it has been raised to the 
dignity of a system about which more will be said in the next 
chapter. 

Treatment of disease by exercise and massage has suffered 
from the ignorance of its undereducated practitioners, but 
more often from the vague and indefinite way in which its pre- 
scription has been given. A prescription should be written in 
detail, giving the nature, strength, and number of movements, 
and each movement should be carefully supervised. Only too 
often a slight difference in position may bring into action muscles 
that should be at rest, or vice versa. Every move should be 
pushed to its full limit of efficiency. The seances should be 
frequently repeated; one-half hour daily is better than one and 

' Douglas Graham, Massage, fourth ed. (Lippincott). 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 335 

one-half hours every third day. Every attendant condition 
should be made as favorable as possible. Fresh air should be 
supplied in abundance, and treatment given in the open air if 
possible. 

The personality of the operator must be an inspiration to the 
patient, for without co-operation but little can be expected from 
exercises of strength, skill, or endurance. He must insist on accu- 
racy and precision in every movement, however simple it may 
seem to the casual observer. The value of this discipline for the 
patient is not to be lost sight of. It was shown among the men- 
tal and moral defectives, described in a previous chapter, and in the 
MacLean Asylum Edward Colles^ noted not only the marked 
increase in appetite, improvement in digestion, heart action, 
and carriage of inebriates under his charge, but also a quicker 
mental response, a better moral stamina, which leads him to 
believe that gymnastic exercises demonstrate their therapeutic 
value in the restoration not only of physical vigor, but also of 
mental and moral health. 

^ "Drunkenness and Inebriety," P. E. Review, vol. v, No. 3. 

Bibliography 

Medical and Orthopoedic Gymnastics, Anders Wide (Funk & Wagnalls Co.). 

Treatment by Physical Methods, T. S. Dowse (Treat & Co., N. Y.). 

The Elements of Kellgren's Manual Treatment, E. F. Cyriax (Bale & Sons). 



CHAPTER XIX 

MASSAGE AND VIBRATION 

The word "massage" — Greek, massein, to knead — is applied 
to the systematic manipulation of the body surface by the hands 
in movements of stroking, pinching, kneading, and striking. 

Passive motion consists in flexion, extension, and other 
movements of joints and limbs by an operator or machine with- 
out the co-operation or resistance of the patient. Both have 
been widely used since the beginning of history. Travelers have 
brought accounts of their employment in Turkey, Africa, Siberia, 
Lapland, Japan, China, and the islands of the Pacific. The 
Lomi Lomi of the Sandwich Islands is spoken of with enthusiasm, 
for its powers of relieving the stiffness and soreness of fatigue and 
procuring rest and sleep. 

The history of massage has been checkered. The priests of 
Egypt used friction and kneading for rheumatic pains and neural- 
gia, and the priestly caste of India have always known and prac- 
ticed it. The Greeks had a class of paidotribes, or trainers, who 
acquired great skill in the manipulation of the body, just as at 
the present time the call of the blind masseur is a familiar sound 
in the streets of Tokyo. The Romans followed the Greeks, from 
whom so many of their customs were borrowed, but with them 
it often became a means of escaping the more rigorous forms of 
exercise and of removing the effects of overeating and drinking, 
the forenoon of the luxurious patrician being devoted to the bath 
and general massage. 

It has had its eras of popularity and its seasons of neglect — 
popularity usually due to the personality and skill of an operator 
or school of operators, and neglect following its indiscriminate 
use by unskilled persons. 
336 



MASSAGE AND VIBRATION 337 

A great impetus was given to its employment by Ling and 
his disciples in Sweden, and it now forms part of the Swedish 
system of remedial gymnastics. 

In the middle of the last century Beveridges' rubbers were 
well known in Edinburgh, and their success carried it from that 
medical center throughout Europe. It then declined, but has 
been revived on a more solid and scientific basis by Fox, Nor- 
strom, Kellgren, Douglas Graham, and especially by Mezger, of 
Amsterdam, whose classification is the one habitually followed 
to the present day. 

Its recognition as a therapeutic agent has been delayed 
by the failure to distinguish between true massage and un- 
skilled rubbing, which merely requires muscular strength, a 
certain manual dexterity, and good will. To be a successful 
masseur, one must possess these quahties before beginning the 
training necessary to learn its possibihties, but its practice 
should be preceded by an intimate and special knowledge of 
anatomy, the disposition and thickness of muscle groups, their 
septa, the point where muscle changes to tendon, the situation 
and course of the veins and arteries, their anastomoses, the 
location of the nerve-supply, the movements of a limb, the 
changes about the joint caused by movement, and the situation 
and extent of synovial cavities and tendon-sheaths. 

This knowledge should be practical and continually confirmed 
or corrected when the parts are at rest and when at work. In 
addition to this there must be that touch, firm, insistent, yet 
gentle, that adapts itself to the hills and hollows of the body 
surface, as if by instinct, and a buoyant constitutional vigor 
to withstand the exhausting character of its practice. Strong 
physique and good health are essential. Personal cleanliness is 
of the utmost importance, while thoroughness in carrying out 
a prescription to the minutest detail is necessary to insure the 
confidence of the doctor and patient. No one can hope to be 
a successful masseur who has not a highly developed muscular 
sense and who is not clever with his hands. A perfect hand for 
massage should be soft, smooth, dry, and fleshy. It should have 



338 EXERCISE IN EDUCATION AND MEDICINE 

great muscular power, suppleness, flexibility, and firmness oi 
grip. A damp, cold, and clammy hand is totally unfit for such 
work. Talking with the patient during a treatment is distracting 
and undoubtedly mars the good effect of the operation, although 
the business success of some operators is due as much to their 
conversational powers as to their real abihty. The successful 
practice of this art will always be Hmited to the few who are 
willing and able to devote the time and study necessary for 
the thorough acquirement of its technic. 




Fig. 228. Fig. 229. 

Fig. 228. — Normal voluntary curve of fatigue of the flexor muscles of the middle finger 

of the left hand, with a weight of 3 kilos and rhythm of two seconds. 
Fig. 229. — Curve of the same muscles with the same weight and rhythm, after massage 
for three minutes (after Maggiora). 

The action of massage was studied by Mosso and Maggiora, 
who chose for their experiments the fatigue curves of the right 
and left middle fingers in maximum voluntary flexion, every 
two seconds, with a weight of 3 kilos.^ These records were 
taken at 8 and 11 in the morning and at 2 and 5 in the after- 
noon, without massage, and the following day, under the same 
conditions, after a friction and kneading of three minutes. 
The average of these results proved that the muscles did 
twice as much work after the massage. Maggiora (Figs. 229- 
231) discovered that extension of the period of massage did 

^ Graham, Recent Developments in Massage. 



MASSAGE AND VIBRATION 



339 



not produce any greater results in the capacity for work, five 
minutes obtaining all the needful effect. His experiments 
on the comparative value of the various manipulations proved 
that little difference existed in the effect of friction and per- 
cussion. There was a greater increase of working capacity 
after the use of petrissage than from either of the other move- 
ments, but the best results were obtained by using in turn all 
three. The effect of massage upon muscles weakened by fasting 
was such as to restore them temporarily to their normal condi- 




Fig. 230. Fig. 231. 

Fig. 230. — Fatigue curve of flexors of right middle finger after a walk of 10 miles. 
Fig. 23 1 . — Sliows the influence of massage for ten minutes upon the same muscles already 
indirectly weakened by walking. Weight, 3 kilos; rhythm, two seconds (Maggiora). 

tion. It also restored a normal fatigue curve reduced and 
shortened by a wakeful night (Figs. 232, 233). After an intense 
prolonged intellectual strain of five hours, in the final examina- 
tion of medical students, Maggiora's fatigue curve was one-fifth 
of the normal. An hour later, after ten minutes of massage, the 
fatigue curve was almost completely restored. Perhaps the most 
interesting results obtained were in his studies of artificial anemia 
of the muscles. After compressing the brachial artery the finger 
could contract only 11 times in comparison to 265 times under 



340 EXERCISE IN EDUCATION AND MEDICINE 

normal conditions. While the arterial current was still shut off 
three minutes of vigorous massage was given, after which the 
finger could contract only 9 times, proving that massage had 
no effect when the blood-supply was intercepted. From these 
experiments, it is evident that massage essentially affects the 
local circulation by bringing a greater quantity of nutrition to 
the muscles and removing the poisonous products loosened by 
their action. Its action in improving muscle tone, in postpon- 
ing the onset of fatigue and hastening recovery from it, has long 
been recognized by athletic trainers. In preparing athletes for 




Fig. 232. Fig. 233. 

Fig. 232. — Fatigue curve of flexor muscles of middle finger of right hand after being awake 

one night. 
Fig. 233.— Shows the effect of ten minutes' massage upon the same muscles (Maggiora). 

a contest, general massage is always given by friction, kneading, 
pinching, and stroking, lubricating the surface with some oily 
liniment. After a hard race or other contest it is a matter of 
common knowledge among trainers that a five-minute treat- 
ment will enable an athlete to repeat or continue a performance 
otherwise impossible. 

Massage differs radically from active exercise in its capacity 
to feed muscular tissue without fatiguing or even employing 
the will-power of the patient. It is the most economic form of 



MASSAGE AND VIBRATION 



341 



exercise on the nervous system, and yet its potency is shown by 
the increase of red blood-corpuscles and hemoglobin, and by the 
exalted rate and force of the heart-beat without a corresponding 
change in the arterial tension. It accomplishes these results by 
decreasing resistance in the peripheral vessels, by the removal 
of the poisons of oxidation, and by mechanically moving the 
blood-current forward in the lymph-spaces and venous channels. 
It thus stimulates the circulation, respiration, nutrition, and 
excretion. 




Fig. 234.- 



-Effleurage of the forearm. Note the distention of the veins above the hand 
that is passing upward. 



There are four principal forms of manipulation: 
(i) Stroking — effleurage — in which the hand is passed lightly 
over the skin, with pressure from the periphery to the center, 
following the course of the venous circulation and the long direc- 
tion of the muscles from their insertion to their origin. It may 
be performed by stroking with the palm of one or both hands, 
with the thumb or tips of the fingers (Fig. 234). The two hands 
are used upon the large fleshy parts of the thighs and buttocks 
or upon the chest, back, and neck. The thumb is used on small 
muscles hemmed in by bones, such as the interossei of the hand 



342 



EXERCISE IN EDUCATION AND MEDICINE 



or foot or the anterior muscles of the leg. The tips of the 
fingers are used around the joints of the knee, ankle, elbow, or 
wrist, the fingers adapting themselves to the shape of the part 
worked upon. 

EfHeurage is a surface manipulation. The fingers are brought 
into hght contact only with the skin of the patient. Its value 
consists in its lightness and delicacy of touch. It is like stroking 
a cat. For that reason the tips of the fingers are peculiarly 
adapted on account of their sensitiveness. The movements are 




Fig. 235. — Friction of the erector spinas. 



adapted to such parts as the forehead, temples, face, and other 
parts in which the bone is close beneath the skin. They are 
soothing and sedative, while engorged veins and lymph chan- 
nels are also unloaded (Fig. 234). This form is employed at 
the beginning of treatment for fractures, sprains, and freshly 
inflamed synovial membranes, and in all chronic cases where 
the tissues are matted and sodden, requiring the absorption of 
an exudate. 

(2) Friction. — A firm, deep circular movement performed 
by the thumb, tips of the fingers, or by one hand opened or 



MASSAGE AND VIBRATION 343 

clenched. The thumb is employed on the small surfaces of the 
face or extremities. Friction by the tips of the fingers is used 
around joints, the fleshy part of the thigh, the arm, and the lum- 
bar region requiring the entire hand. (See Fig. 235.) Friction 
should proceed in the same general direction as the stroking move- 
ments, which should always immediately precede or follow it. The 
products of fatigue congregating in the deep muscular tissue are 
thus thrown into the circulation, the gentle manipulations of 
stroking readily carrying them into the superficial veins. It 
affects all deep-seated structures embedded in muscular masses, 




Fig. 236. — Petrissage of the calf muscles. 

and should be used along the sciatic nerve in the treatment of 
sciatica and over the abdomen to unload the colon. 

(3) Petrissage, Pinching, or Grasping. — Performed by pick- 
ing up the skin and subcutaneous tissue between the thumb and 
fingers and manipulating it with an amount of force not suffi- 
cient to cause pain. In this movement the skin moves with the 
hand of the operator, and the underlying structures are thus 
massaged by it under the pressure of the fingers. It is most ad- 
vantageously done by the thumb opposed by the first finger, 
by the fingers opposed to the palm of the hand, or by the two 
hands opposed to one another. The thumb and fingers are 
used to reach individual muscles and small groups, such as the 



344 EXERCISE IN EDUCATION AND MEDICINE 

muscles of the hand, foot, forearm, and upper arm. The larger 
muscle masses of the thigh and calf require the use of the fingers 
opposed to the thumb and hand (Fig. 236), or both hands, the 
muscle being rolled beneath them and pressed against the bone. 
This has the same effect as friction on the deep structures, and 
is better for sensitive, easily irritated surfaces, the skin moving 
with the hand like a glove. The movement should always be 
gradual, proceeding from the periphery inward. It should fol- 
low the course of the venous blood and lymph, but in the chest 
and back the course of the muscle-fibers and ribs. The hand 
should never be removed entirely from the surface, but while 
the pressure is being given the skin should be moved with the 
hand and the part squeezed inward or toward the direction of the 
venous flow. The tissues acted upon by this manipulation are 
both superficial and deep — skin, fat, and muscles of the thorax 
and extremities, as well as the nerves, arteries, veins, and lymph- 
atics. While the manipulation is firm, it should not be hard 
enough to give pain or even discomfort. In using the hand make 
the thumb the fixed point, and draw the hand to it, or make 
the fingers the fixed point, drawing the rest of the hand to them. 
It is the favorite means used to improve muscular nutrition in 
conditions of fatigue, in atrophy, in obesity, or other forms of 
muscular degeneration. 

(4) Striking — Tapotement or Percussion. — This manipulation 
comes under many names, such as clapping, beating, knocking, 
or hacking. It is done for small surfaces by patting with the 
open hand, or by slapping with the palm cupped to leave a layer 
of compressed air between the hand and the surface to be manipu- 
lated, a bombastic movement that is familiar to every frequenter 
of the Turkish bath. Its action on the skin, superficial nerves, 
and vessels is stimulating. Hacking is performed with the ulnar 
border of the hand, and is used along such nerve-trunks as the 
sciatic or spinal nerves (Fig. 237). Where the bone lies close to 
the skin at the ankle- or knee-joints, or in manipulations of the 
scalp, this movement should be performed by the tips of the 
fingers, but over the fleshy regions of the thigh and buttocks 



MASSAGE AND VIBRATION 345 

the clenched hand may be used. Each blow stimulates the 
nerve powerfully and causes involuntary contraction of the 
muscle. When the blow is heavy and rapidly repeated it may 
even produce local anesthesia. The blows should be quick and 
sharp, but not strong enough to bruise the muscle and produce 
after-soreness. All striking movements should be done with a 
loose wrist, and where the closed hand is used the flat of the 
fingers should be parallel with the surface and the movement 
sharp and snappy rather than strong and heavy, swinging freely 




Fig. 237. — Tapotement of the back with the ulnar surface of the hands. 

from the wrist, the arms kept close to the sides. The stimulating 
effect of tapotement on the reflexes is very different from that of 
the other forms of massage already described and it can be used 
strongly and effectively over the large muscle masses of the but- 
tocks, back, and trunk. It is commonly used in cases of neu- 
ralgia, neuritis, and paralysis, in which stimulation is needed. 

The use of tapotement has been elevated into a system of 
therapeutics, named by Abrams spondylotherapy,^ and by Louis 
von Cotzhausen reflexotherapy, a better term, by the use of the 
percussor, plexor, or even the knuckles applied over the spinous 
processes. 

The relation of certain symptoms to pain at the exit of 

^ Spondylo therapy, A. Abrams, Philopolis Press, San Francisco. 



346 EXERCISE IN EDUCATION AND MEDICINE 

the spinal nerves was noted in 1834 by William and Daniel 
Griffin, of Edinburgh and London, whose report of 148 cases 
brought them to the conclusion that tenderness in the region of 
the spine may be secondary to visceral disease. 

The Swedish gymnasts had observed tenderness over the 
fourth and fifth dorsal nerves in cases of heart disease, and 
over the sixth, seventh, and eighth in affections of the stomach. 

It is a well-known fact that repeated blows over the seventh 
cervical stimulates the vasoconstrictors of the heart and lessens 
its size. This has been described by Abrams as the heart reflex 
of contraction. The same phenomenon can be obtained in the 
heart by the application of friction over the pericardium or by 
the application of cold. It is a frequent experience to find the 
area of heart dulness become smaller after continual percussion 
in the examination of a patient's lungs, due either to reduction 
in the heart size or to dilatation of the lungs. Similar reflexes 
for the lungs and abdominal organs can be obtained by this 
form of tapotement at dift'erent levels of the spine, although with 
less distinctness. Abrams' method is to use rapid blows for about 
five minutes, broken by short intervals of rest, and by this 
means he claims that contraction or dilatation of an organ can 
be governed almost at will- 

A fifth manipulation might be added — that of shaking or vibra- 
tion. Shaking involves movement of the whole body or region 
to be treated, while vibration is a lesser motion, in which the body 
or region remains at rest while the surface and structures imme- 
diately beneath it are affected. The term "tremble pressing" 
accurately describes it. These manipulations are exhausting to 
the operator and difficult to perform skilfully. 

Vibration in a simple form was used by Ling, but it has been 
importantly developed by Henrik Kellgren and his school, new 
and improved manipulations being added especially for the 
treatment of the nerve-trunks. ^ 

Two or more finger points are kept in continuous contact 
with the part to be manipulated, the joints of the finger, wrist, 

^The Elements of Kellgren's Manual Treatment, Edgar T. Cyriax (Bale & Sons). 



MASSAGE AND VIBRATION 



347 




Fig. 238. — Stationary up and down 
nerve vibration, using thumb and finger 
for a spinal nerve. 



and elbow being kept loose. The movement is produced by a 
contraction and relaxation of the muscles of the forearm or 
shoulder, the excursion at the wrist-joint varying from | to i inch. 
The amount of muscular force employed by the operator is slight 
and the movement delicate. The rate is about twelve to the 
second. This may be exe- 
cuted over one point, station- 
ary vibration, the vibration 
being exceedingly small, as in 
the treatment of conditions 
of the eye. Where much 
pressure is desired the fore- 
finger and thumb are brought 
together and the tip of the 
thumb is applied to the part. 
Stronger pressure can thus 
be used to reach such deep- 
seated structures as the spinal 

nerves or the great sciatic nerve in the buttock. Running vibra- 
tions with the fingers are used along the course of nerves. 

Other complex forms are described under the name of suc- 
tion, dispersing, and nipping vibrations, the speed running from 
six to twelve to the second. Running nerve frictions can be 
given to any region of the body, arms, head, or legs, and they 
are frequently used in a general treatment by one or two opera- 
tors working simultaneously. The operator begins at the sides 
of the head by rapid cross movements, in which the finger-tips 
are drawn across the course of the nerve-trunks down the side 
of the neck, over the shoulder, down the palmar surface of the 
forearm, back up the dorsal surface, down the side of the spine, 
across and over the back of the leg, coming up the anterior sur- 
face of the leg and along the trunk in the anterior axillary line, 
and so on to the finger points. When both hands are used the 
path of movement may vary, as shown in Fig. 239. 

These running frictions are stimulating to the cerebral, 
spinal, and sympathetic nervous system, and are accompanied 



348 



EXERCISE IN EDUCATION AND MEDICINE 



by constriction of the vessels followed by dilatation. The patient 
always experiences a sense of exhilaration after their use. All 
these movements require great skill and long training, and it is 
for that reason more than any other that the various mechanical 
forms of vibration have been designed. These machines have the 
advantage over the rapidly tiring and uncertain human hand 
of keeping the amount of resistance con- 
stant, diminishing or increasing it as desired, 
while the rate may also be increased. They 
will be described fully in the next chapter. 
General massage is best given at an 
hour midway between meals and never 
immediately after eating. The order in 
which the manipulations are given is as 
follows : 

The operator starts with the feet and 
gently but firmly pinches up the skin and 
subcutaneous tissue, rolling it between 
the fingers and thumb until both surfaces 
of each foot have been covered. With 
the thumbs and fingers the small muscles 
of the foot are kneaded, special attention 
being devoted to the interosseous groups, 
which require slow deep pressure from the 
thumbs. Care should be taken to avoid 
bruising of muscle and skin against the 
underlying bones. The foot is then grasped 
and all the natural movements of the toes 
and ankle are rehearsed. Next the region of 
the ankle is dealt with in the same fashion, 
and stroking movements are made from the toes to the leg to 
empty the superficial veins of the foot. The leg is next treated 
by circular friction with the fingers, by deeper grasping of the 
areolar tissue, and, last, by industrious and deep pinching of 
the larger muscular masses, which for this purpose are put in a 
position of complete relaxation (Fig. 236). 




P'ig. 239. — Course taken 
in running nerve frictions 
(Kellgren). 



MASSAGE AND VIBRATION 349 

For the large muscles of the calf and thigh both hands act, 
the one contractmg while the other lessens its, grip. The firm 
muscles in the front of the leg are rolled under the cushions of 
the finger-tips. At brief intervals upward stroking is given from 
ankle to knee to favor the flow of venous blood-currents. The 
same process is continued for the hands and the arms. Especial 
care is now given to the muscles of the loins, back, and neck, 
which are subjected to frictions, kneading, and striking with the 
ulnar border of the open hand (Fig. 237), followed by upward 
stroking of the loins and back, the same manipulation being 
directed downward and outward from the head to the shoulders. 
The abdomen is then treated by pinching the skin and underly- 
ing tissue, deeply grasping the entire muscular walls with both 
hands, pinching and rolhng them. Massage of this region con- 
cludes with deep kneading by the heel of the hand in a succes- 
sion of rapid, deep movements, passing clockwise in the direc- 
tion of the colon. The chest is then manipulated upward from 
the sternum along the line of the pectoral muscles by pinching 
and kneading of the muscle masses of each side. The face is 
not usually treated in general massage, but the sides of the neck 
are gently stroked from above downward along the course of the 
internal jugular veins. Each part operated upon should be 
carefully covered after treatment. 

Weir Mitchell, in his treatment of neurasthenia by rest, over- 
feeding, and general massage, describes a constant rise of tem- 
perature after each treatment, and noted a rapid improvement 
in the tone and reaction of the whole muscular system. 

Massage can be applied to special parts and organs, such as 
the eye and the ear. Dehcate circular friction over the eyelid 
accompanied by hght pressure with the finger-tips may be ap- 
pHed, but should never be painful. Stroking movements hori- 
zontally outward, rather fast, may be performed for from two 
to five minutes once a day for suitable conditions of the eyeball. 
The eyehd itself may be massaged by inserting a smooth flat- 
tened glass rod between the lid and the eyeball, massage being 
applied to the lid with the rod as a foundation instead of the 



350 EXERCISE IN EDUCATION AND MEDICINE 

eyeball, which thus escapes undue pressure. Various mechanical 
vibrations may be applied directly to the eyeball at a rate up to 
nine thousand to the minute. Pagenstecher notes a decreased 
tension of the eyeball as a result. This depleting effect, which 
is followed by stimulation, would cause the absorption of old 
inflammatory exudates. 

Alexander Randall describes a simple and valuable method 
of treating the tympanic membranes by vibrations apphed 
by the surgeon, or by the patient, in which the amount can be 
governed in accord with the response of the ear. The pulp 
of the middle finger of one or both hands simultaneously 
is introduced into the meatus, drawing the tragus forward by 
slow rotation, pressed as deep as the opening will permit. Gentle 
pumping movements in and out furnish a massage which is 
mainly by suction, and can be safely continued for thirty to sixty 
seconds at varying rates. It can be as slow as sixty per minute 
or as quick as ten per second, while the degrees of the excursion, 
will regulate the force. Another form of this pneumatic mas- 
sage is performed by the flat of the palm stretched out, laid in 
contact with the auricle, and alternately pressed and released 
with a pumping movement. It is one of the readiest means to 
relieve certain forms of .vertigo, faintness, and frequently lifts 
the burden of deafness and tiimitus when such help is most 
desired. 

The usual fault in giving massage is that too much is given 
at one time, especially in vibrations. The rule of some masseurs 
is to give the patient as much as he can stand. Maggiora's- 
experiments prove that the maximum effect on a part is obtained 
in five minutes. Another mistake is in employing too heavy a, 
hand. Zabludowski's dictum that when massage becomes 
painless it ceases to be massage is false. A patient should never 
feel bruised or exhausted, although a pleasant lassitude is one 
of the most valuable effects. 

The use of lubricants, such as cocoa butter or vaseline, can 

^ Alexander Randall, "More Efficient Methods of Aural Massage," Annals, 
of Otology, September, igii. 



MASSAGE AND VIBRATION 35 1 

in most cases be dispensed with. Talcum powder will dry a 
moist surface and prevent the pulling on hair, and practically- 
all manipulations can be given equally well through a light cotton 
or silk undergarment. 

Massage should be avoided in certain skin affections, as 
eczema, acne, and other skin eruptions, in wounds, burns, and 
erysipelas, in tumors and purulent inflammations, and in acute 
disease of the bone tissue. It should not be used in the acute 
stages of severe constitutional or local diseases where complete 
rest is necessary, and it should be allowed only with great pre- 
caution in pregnancy and in the presence of renal disease. Its 
place in the treatment of sprains, fractures, and other surgical 
conditions and its value in medicine are considered more fully in 
their appropriate places. 



CHAPTER XX 

MECHANICAL MEANS FOR MASSAGE AND 
EXERCISE 

The progress of treatment by vibration and massage was 
and is retarded by the difficulty in securing any uniformity of 
method. The practice is an art, and not all of its practitioners 
are artists, with the result that too often extravagant claims are 
built on most inadequate foundations of knowledge and ex- 
perience and discredit is brought on a most valuable therapeutic 
procedure. 

Mechanical means have been devised to standardize the 
amount and strength of vibration and movement, and so allow 
of the prescription of a definite dose by the physician who may 
lack the skill to give the necessary manipulations himself. This 
is what gave the Zander Institutes their vogue in Europe, and has 
been even more true in the case of treatment by vibration in which 
the mechanical ingenuity of so many has had free play. Its very 
ease of application has,' however, led to a notorious abuse of 
vibration by applying it to unsuitable cases, and still more 
commonly by making the application too long and too severe. 
The power of properly applied vibratory movement over the 
heart-rate and pulse volume, over pain, and over deep-seated 
organs, through the spinal nerves, has been well estabhshed for 
many years, and about 1878 Dr. J. Mortimer Grenville began 
his experiments in the relief of pain by vibration. Acute pain 
he likened to a high note in music produced by rapid vibrations. 
Dull aching pain he likened to low notes produced by slow 
vibrations. He attempted to bring discord into the rhythm of 
morbid vibrations by means of his percutor, in which the rate 
of the blows could be changed at will. The modern vibrator is a 
development and expansion of this idea with others added to it. 

3S2 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 



353 



All forms of vibration lessen nervous sensibility, even to the 
relief of acute pain, and for the time being abolish the sense of 
fatigue just as does massage. 

Vigoroux attempted to apply the same principle by placing 
a large tuning-fork on a resonating box opening at both ends, 
into which was placed the part to be treated. Good results were 
obtained in the lightning pains of ataxia and in hysteric condi- 
tions. 

Boudet devised a helmet, with vibrations at the rate of loo 
per second, which gave a sedative effect, normal patients being 
put to sleep by this means. 




Fig. 240. — The Zander vibrator. 

While a great many machines have been invented, they 
fall under two main types — first, the rigid arm vibrator, illus- 
trated by the machines of Zander and Kellogg, and, second, the 
portable vibrator, like the dumb-bell vibrator, as designed by 
Kellogg (Fig. 241). 

A good portable machine should be readily adjustable in rate 
and length of stroke, and should be capable of giving percussion 
and a rotary boring movement. The weight of the vibrator has 
been much discussed, but Eberhart, of Chicago, happily com- 
pares them to various-sized hammers. 
23 



354 



EXERCISE IN EDUCATION AND MEDICINE 



"If one wishes to drive a small nail he could do so with 
either a sledge hammer, an ordinary hammer, or a tack hammer. 
The sledge hammer would drive it at one blow, but there would 
be much superfluous power; the ordinary hammer would drive 
it in four or five strokes ; the tack hammer would possibly require 
a dozen blows. The final result would be the driving of the 
nail." 

This is not a complete parallel, however, for three points 
must be considered in the application of any instrument — (i) the 




Fig. 241 .^Kellogg's dumb-bell vibrator. 

length of the stroke; (2) its rate; (3) the amount of pressure. 
All three can be varied within very wide limits by a mechanism 
of adjustment, and modified in their effect by the applicator 
used, the chief attachments for a well-designed machine being 
a rubber brush, a ball of hard rubber, and a second ball of soft 
rubber for the throat and for the large muscle masses like the 
erector spinas, a hollow rubber ball for the treatment of the eye, 
a flat disk, a vacuum cup, and special vibratodes of hard and soft 
rubber for rectum and vagina (Fig. 242). 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 



355 



The late Maurice F. Pilgrim, in his little work on vibratory- 
stimulation, classifies the movements into (i) stimulation, (2) 
vibratory stimulation, and (3) vibration. 

Stimulation is produced by a medium stroke and light pres- 
sure with the brush attachment for increasing the blood-supply 
to a region improving its tone and nutrition. To produce mild 
stimulation an application should last from three to seven 
seconds. 




Fig. 242. — Various attachments recommended for use in the application of mechanical 
vibratory stimulation to the various organs and cavities of the body (Pilgrim): i, Rubber 
brush; 2, rectal and vaginal attachment (rubber); 3, rubber ball; 4, throat attachment 
(rubber); 5, eye-cup (rubber). 



Vibratory stimulation is applied by a rubber ball with a 
medium stroke and deep pressure, the treatment lasting from 
eight to twelve seconds over one spot. This is recommended for 
cases in which the viscera are to be reached by acting on the 
spinal nerve roots (Fig. 243). 

Vibration is produced by a heavy stroke and deep pressure 
with the hard-ball attachment. It should not be given for more 
than fifteen to twenty seconds, and is used to inhibit a nerve 
that is giving pain. Overstimulation is the besetting sin of most 
operators, and while not permanently harmful it ruins the thera- 



356 



EXERCISE IN EDUCATION AND MEDICINE 



peutic effect for which we strive. Vibration is given by direct 
percussion in which a series of blows fall upon the skin in rapid 
succession. This is a refinement of tapotement and of the percus- 
sing hammers invented by Graham and used so extensively by 




Fig. 243. — Diagram showing areas in the spinal cord from which the nerves controlling 
the various organs and parts of the body are given off. The red hnes in the table indicate 
vasomotor areas. Stimulation of the centers, indicated in the diagram, will affect the 
organs controlled by them, see table at the left of the diagram (Pilgrim). 



Abrams. When much force is used the deep structures can be 
profoundly affected. It is given also by lateral oscillations 
where the part vibrates with the instrument from side to side. 
A boring circular movement can also be produced by the port- 
able machine, in which a revolving shaft is thrown out of balance 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 357 

by carrying on one end an arm or wheel overweighted on one 
side. As the shaft revolves the end goes in a circle instead of 
on a fixed axis, and by holding it at right angles to the part to 
be operated upon the movement given to the tissues is circular 
or boring in character. 

The rate used in most vibrators is from one thousand to 
six thousand vibrations per minute. Dr. J. H. Kellogg has 
been experimenting by means of air-pressure on higher rates 
of vibration than can be obtained in a machine. This pneu- 
matic vibration produces a musical note, ranging in tone as 
the rate varies from two thousand to two hundred thousand 
per minute. With a column of from 40 to 60 pounds pressure 
it depresses and blanches the skin, emptying it of blood and 
lymph while the pressure is applied at right angles to the sur- 
face. When the air is applied parallel to the skin, with from 30 
to 60 pounds pressure, the skin rises in ridges or folds, and 
blisters may be produced if the application is continued. 

Both these forms are useful to produce reflex or derivative 
movements. When applied over the nerve-supply of special 
viscera, such as the lungs or the liver, it is always followed by a 
sense of warmth and tingling. This pneumatic vibration of 
Kellogg's is the most rapid form known, and the only objec- 
tion to it is the somewhat loud musical note which accom- 
panies it. 

The principle of circular movement, as described in the 
portable vibrator, was applied by Kellogg in 1880 to a vibratory 
chair placed upon a platform supported by rubber balls to pre- 
vent transmission of the movement to the room, and a rate of 
100 vibrations per second was secured. The patient who seats 
himself in this chair for four or five minutes will experience 
stimulation to the peristalsis, improvement of the circulation, 
as shown in the warming of cold feet and hands, and disappear- 
ance of fatigue. The effect can be concentrated on one part 
by grasping the chair and contracting the muscles. If the feet 
are fixed to the chair the patient experiences numbness and 
tingling. If the patient stands on the foot-board, or sits on an 



358 



EXERCISE IN EDUCATION AND MEDICINE 



ordinary chair with feet against the vibrating chair and with mus- 
cles contracted, the effect goes from the feet to the legs (Fig. 244). 
If the patient seats himself bent forward, vibration of the abdom- 
inal viscera can be obtained, and if the patient leans backward 
against the chair-back the eft'ect on the spinal cord can be empha- 
sized. The patient standing by the chair with the hands grasp- 
ing the chair-back can increase the eft'ect by the closeness of the 
grip and the rigidity of the hands and arms. By applying the 
same mechanism to horizontal bars from 4 to 10 feet in length, 




Fig. 244. — Vibratory chair, showing application of vibration to the feet only (Kellogg). 



vibrations of the fingers can be obtained by placing the hands 
on the upper part of the bar with the fingers widely separated. 
This can be extended to the hands by grasping them with the 
wrist and forearm relaxed, and to the arms, shoulders, chest, 
spine, and head by contracting the muscles of the chest, arms, 
shoulders, and head (Fig. 245). Treatment is always followed 
by a feeling of numbness, tinghng, and then warmth. When 
properly applied, with precautions against overstimulation, these 
forms of vibration have great therapeutic value. The heart- 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 359 

rate can be lessened and its force increased, although care must 
be taken of the depressing effect produced by percussion directly 
over the heart. By means of vibration over the submaxillary 
region a copious flow of saliva can be produced, and a sense of 
hunger stimulated when the vibrator is applied over the epigas- 
trium. The fatigue of neurasthenia can be relieved, and certain 
forms of backache, when due to muscular strain, yield quickly 
to its influence, while the effect of stimulation and vibrations 
around the course of the colon is most marked. 




Fig. 245. — ^The vibrating bars ("Kellogg). 

Among the special applications of vibration may be men- 
tioned that of the tympanic membrane. Many instruments 
have been invented for this purpose, using the mouth, the 
hand, and electricity as the motor power. The vibrations from 
the voice form the normal massage which sets the membrane in 
motion, many of the appliances for improving the hearing doing 
so by transposing the rate of vibration or pitch out of an ill-heard 
register to a higher key. 

In all forms of rhythmic massage applied by mechanical 



360 EXERCISE IN EDUCATION AND MEDICINE 

power there is great danger of causing nerve degeneration from 
overstimulation, and for this reason it is better to use the 
manual treatment described by Alexander Randall in the last 
chapter.^ 

A form of vibration or, more properly, a form of exercise 
is obtained from the sinusoidal current, in which the electricity 
is applied intermittently, the current being reversed after each 
intermission. This form has the advantage of being painless 
and of producing most vigorous muscular contractions. Its dis- 
covery was the joint work of Drs. J. H. Kellogg and d'Arsonval. 
By its means groups of muscles can be exercised while the 
patient is passive. The muscles under its influence contract 
with as much vigor as though one were chopping wood or climb- 
ing a hill, although the patient may be lying quietly on a lounge. 
Its value is greatest in cases of obesity, diabetes, or advanced 
heart diseases, where the patient is too feeble to take the requisite 
amount of exercise by walking or other forms of muscular activity. 
It can also be applied successfully to increase muscular activity 
of the intestinal tract. 

The use of mechanical means for the application of exercise 
in therapeutics was first systematized and employed in a com- 
plete way by Dr. Gustaf Zander, of Stockholm, about 1857. 

He there established and directed the first Zander institute, 
and has been actively engaged in the practice of medico-mechan- 
ical gymnastics, lecturing on the subject at the medical school in 
Stockholm until his retirement, when he was succeeded by his 
eldest son. Zander has devised nearly one hundred machines 
to give his exercises and manipulations, and his system of 
mechanotherapy has enjoyed a wide popularity in Europe and 
has a considerable following in America. Zander institutes are 
found in Boston, Baltimore, Philadelphia, St. Louis, San Fran- 
cisco, and elsewhere, while over seventy sanatoria are supphed 
with some of his apparatus. The machines are in three series. 

First Series. — Apparatus set in motion by the muscular power 
of the patient. 

1 Annals of Otology, September, 1911. 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 36 1 

Second Series. — Apparatus set in motion by means of some 
motor. 

Third Series. — Apparatus exercising by the weight of the 
patient's body or by mechanical arrangements, a corrective pres- 
sure or tension. 

They are classified according to their physiologic effects into 
four sections. 

(i) Apparatus for Active Movements. — To exercise and de- 
velop arms, legs, trunk, and balance. These machines are 




Fig. 246. — Machine for flexion and extension of the forearms. 

thirty-eight in number. A typical example is Fig. 246 for fore- 
arm flexion. Its application may be reversed and used to exercise 
forearm extension. A number of other machines are made 
reversible, a necessary economy that is at once apparent. In 
the balance machine the patient sits astride a saddle-shaped seat, 
grasping a fixed handle-bar. A rolling rotary movement is given 
the seat by motor power, and to preserve the equilibrium the pa- 
tient must use all the muscles of the loins and abdomen in turn. 



362 



EXERCISE IN EDUCATION AND MEDICINE 



(2) Apparatus for Passive Movements. — To manipulate the 
hands and fingers for chest dilatation, trunk rotation, and 
pelvic elevations. The machine for chest dilatation merits more 
than passing notice. It is called "The Tower" (Fig. 317), and 
the movement is performed by two crutch-like appHances passing 
beneath the arm-pits and retracting both shoulders, while the 
chest is thrust forward rhythmically by a cushion applied against 
the back of the patient, as shown in the illustration. The rate is 




Fig. 247. — The "horse," to give vibration of the whole body (sitting saddleways). 

set to correspond with normal respiration, and the thoracic 
walls are expanded and stretched by its use. 

(3) Apparatus for Mechanical Operations, Including Vibra- 
tion, Percussion, Kneading, and Friction. — Vibration is given to 
the whole body by the jolting movement of a saddle-shaped seat 
(Fig. 247), and the Zander vibrator (Fig. 240) is adjusted to give 
about 500 strokes a minute to the feet, legs, chest, or abdomen. 
Four machines are devoted to percussion. Fig. 248 is provided 
with four beaters for tapotement along the spine. This machine 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 



363 



has been called the "digitalis of the medical gymnast," from its 
action in slowing the heart-beat. One machine is devoted to 
kneading the abdomen, and six to friction of the arm, fingers, 
leg, foot, back, and abdomen. 

(4) Orthopedic Apparatus. — They are eleven in number, and 
are designed for suspension, rotation, and lateral pressure. 




Fig. 248. — Zander's back percussor. 

A complete outfit requires at least 3000 square feet of space, 
with consulting and resting rooms and a gas engine or other 
motor. The resistance is supplied by a weight and lever instead 
of a pulley weight in all the machines requiring voluntary ac- 
tion from the patient. This can be augmented by mioving and 
clamping the weight at any point of the graduated scale marked 
on the lever. They are arranged to comply with Schwann's law 
of muscular contraction, which states that with increasing con- 
traction the muscle is able to accomplish less work. The re- 



364 EXERCISE IN EDUCATION AND MEDICINE 

sistance is then made to dimmish during the latter half of the 
movement, a principle neglected in all machines whose resist- 
ance is furnished by friction or elastic traction. In the machine 
for developing the flexor power of the leg upon the thigh the great- 
est resistance occurs when the leg is bent about 30 degrees from 
complete extension, this being estimated as the point of greatest 
power in the knee flexors. Many objections to the use of dupli- 
cate movements may be overcome by employing these machines. 
The amount of resistance is always constant, and can be dimin- 
ished or increased as desired according to the strength of the 
patient. The dose can be accurately prescribed and the un- 
certainty of the human hand, governed as it must be by the 
operator's varying physical condition, can be eliminated. The 
amount of resistance forms a curve, the apex of which is at the 
point of greatest physiologic efficiency, thus making it more 
scientific in its application than the varying hand of the operator. 
A number of similar machines were designed by Herz, C. F. Tay- 
lor, and Kellogg, and numerous modifications have been made to 
simplify the somewhat cumbersome mechanism of the originals. 

Most widely used are those machines in which the pulley- 
weight is the mechanical principle, employed usually to give 
accurate corrective exercises, but frequently to give an all- 
around muscular development. Like the Zander machines they 
take into account the law of "physiologic load," which affirms 
that a certain resistance is required before a muscle can make its 
maximum contraction. This load is increased if the movements 
are to be few in number and slow in rhythm, and decreased for 
frequent rapidly repeated motions. Many so-called free exercises, 
such as deep knee bending, use the body weight for resistance. 

Dumb-bells have been used since the time of the Greeks for 
the purpose of shortening the period required to develop a muscu- 
lar group. Their application is crude and limited, however, in 
comparison to the accuracy and versatility of machines em- 
ploying the principle of the lever or pulley-weight. The direction 
of a dumb-bell pull is always downward, whereas with the 
shoulder attachment of the pulley-weight the drag is lateral and 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 



165 



the high attachment of the pulley reverses the direction of the 
force of gravity. By changing the position of the pulley it is thus 
possible to isolate the action of all the important muscle groups. 
We have records of Captain Chiosso as early as 1829 at work 
in London on a machine which he finally perfected and called the 




Fia 



249-- 



-The polymachinon of Captain Chiosso. An early attempt at a universal exer- 
ciser, employing the pulley-weight principle. 



polymachinon, a portable chest-like instrument of ropes, weights, 
and pulleys (Fig. 249), Among the advantages claimed for it 
were its convenient size, "the space required for it being of so 
little import that it may with ease be employed in an ordinary 
room," and its beauty of line, "the elegant and ornamental struc- 
ture of the whole fits it for a prominent position in the dining- 



f- 



366 



EXERCISE IN EDUCATION AND MEDICINE 



room, library, or boudoir." In spite of these advantages it did 
not make a permanent impression as an exerciser, an article of 
furniture, or as a means of treat- 
ing the dozen maladies for which it 
was claimed to be most beneficial. 





Fig. 250. — Dr. Sargent's first design for 
the pulley-weight, with adjustable weights 
in wooden boxes. 



Fig. 251. — The perfected pulley- weight 
machine (Narragansett Co.), with weights 
attached by moving a foot lever. Single. 



Other machines designed on this principle have been con- 
structed and used for the last fifty years, but the improvement of 
their design, their systematic application to gymnastic training, 
and their wide employment in physical education are undoubt- 
edly due to the efforts of Dr. Dudley A. Sargent of Harvard, who 
has perfected the numerous developing appHances that are 
known by his name. 

In its simplest form the pulley-weight shows one pulley 
attached to the wall at the shoulder level, over which runs a 
rope with a handle at one end. The other end of the rope is 
fastened to a weight carrier, steadied by guiding rods which may 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 



367 



be loaded with iron plates (Fig. 251). This rope may be com- 
pounded by means of another pulley attached to the weight 
carrier so that its excursion is half that of the arm (Fig. 252, A). 




Fig. 252. — Triplex pulley-weight (Narragansett Co.). 



In this way the height to which the weight is lifted is halved, 
allowing twice the range of movement with the same length of 
guiding rod. 



368 



EXERCISE IN EDUCATION AND MEDICINE 






A further elaboration of the pulley-weight uses the floor 
attachment, the rope turning about the pulley at the level of the 
floor, making a downward resistance (Fig. 252, B). 

A third variation, called the intercostal attachment, uses the 
overhead arm pulley, which draws the arms upward (Fig. 252,0). 
In the triplicate machines all three varieties are used at will (Fig. 
252). Attachments are designed for the head by which the mus- 
cles of the neck may be developed, also for the foot, to exercise 
the muscles of the leg and thigh. The quarter circle (Fig. 318) 
is an attachment that goes with the pulley-weight machine for 
keeping the trunk overextended during the arm movements. 

Pulley-weight ma- 
chines have been de- 
signed by Dr. Sargent 
for strengthening the 
flexors of the fingers (Fig, 
253) and for the pronation 
and supination of the 
forearm. Others are used 
for practising the move- 
ments of pushing down- 
ward on the parallel bars 
(Fig. 254) and chinning 
the horizontal bar. In 
these machines the bars 
are set on shding rods 
and balanced by counter- 
weightsj while the resist- 
ance may be increased 
with the strength of the user. They are designed for the man 
who is too weak to engage in the heavy exercises on the parallel 
and horizontal bars, and by their assistance he is enabled to 
develop gradually strength sufficient for the usual feats. 

All movements on the pulley-weights must be of the simplest 
character and slow in rhythm. Unless the movement is slower 
than the falHng of the weight, a jerky, inefficient action is pro- 




Fii 



. 253. — Finger machine to develop flexors of 
the fingers and grasping power (Spalding). 



MECHANICAL MEANS FOR MASSAGE AND EXERCISE 



09 



duced. They need but little co-ordination and may be repeated 
indefinitely without great mental exhaustion. The repeated con- 
tracting and relaxing pumps the blood through the muscles, which 
rapidly increase in size, but if the entire muscular system be 
developed to its physiologic limit a very considerable drain on 
the vitality is inevitable. A man may have powerful muscular 





Fig. 254. — Traveling parallel bars (Nar- Fig. 255. — The nautical wheel in action, 
ragansett Co.), invented by D. A. Sargent The resistance is furnished by friction, 

for developing purposes. 

development without a capacity for prolonged exertion (Fig. 3). 
These exercises should then be combined with others requiring 
skill and endurance if an all-round development is to be ob- 
tained. The simplicity of the movements is such that they are 
easily mastered and the interest in them soon flags. It needs a 
strong determination buoyed with the hope of increased strength 
to continue their use. 



24 



370 



EXERCISE IN EDUCATION AND MEDICINE 



In order to help the imagination, apparatus has been designed 
to imitate the movements of paddling, rowing, sculling, and 
bicycling, using the principle of the pulley-weight or lever. 
Others employ friction to give resistance to the stroke of the 
oar or the turn of the wheel (Fig. 255). 

In the inomotor Dr. Sargent has devised a machine capable 
of exercising all the muscular system while allowing the exclusive 
use of selected muscle groups. He uses the principle of the lever 




Fig. 256. — The Sargent inomotor with ily-wheel in place. 



as applied to rowing and bicychng. After taking his seat the 
operator grasps the handles and pulls. As he braces his feet the 
foot-rest moves forward, turning the heavy fly-wheel. At the 
same time the seat is forced backward by straightening the 
thighs. When extension is complete the wheel is turned by 
shoving on the handles and pulling on the foot-rest by flexing the 
legs (Fig. 256). Work and rest may thus alternate in opposing 
groups, and any combination of flexors or extensors may be 
used. 



CHAPTER XXI 

FLAT-FOOT AND CLUB-FOOT— THEIR TREATMENT 
BY EXERCISE 

The advantage of the upright position is somewhat offset by 
the frequency of deformities due to a yielding of the structures 
concerned with support. The body may yield at the spine, which 
becomes bent and distorted; at the knee-joints, which knock 
together (genu valgus); or at the arch of the foot, which be- 
comes broken down and flattened, causing the deformity known 
as pes planus, flat-foot, everted foot, or pronated foot. 




Fig. 257. — Anteroposterior arch: i, Short plantar ligament; 2, long plantar ligament; 

3, plantar fascia. 

The bony structure of the foot is arranged in the form of two 
arches, anteroposterior and lateral. The anteroposterior arch 
(Fig. 257) is formed by the os calcis, the scaphoid, the three 
cuneiform bones, and the metatarsals, with the astragalus as a 
keystone. It is supported by the ligaments extending between 
the adjacent bones like ties, but more directly by the short 
plantar Hgament (Fig. 257, i) binding the os calcis to the 
navicular. This powerful hgament completes the socket formed 
by the navicular and the os calcis, into which fits the head of the 

371 



372 



EXERCISE IN EDUCATION AND MEDICINE 



astragalus, or keystone of the arch. The other main ligament 
of support is the long plantar (Fig. 257, 2), which extends from 
the body of the os calcis to the proximal, and indirectly to the 
distal, end of the metatarsal bones, through its connection with 
the tendon-sheaths. These may be termed the first Une of de- 
fense in preserving the anteroposterior arch. 

The second Hne of defense consists in some of the short 
muscles of the foot — the flexor brevis digitorum (Fig. 258,- 3) 
and the flexor brevis hallucis (Fig. 260, 3) — assisted by the 





Fig. 258. — The superficial muscles of 
the foot: I, Abductor minimi digiti; 2, ab- 
ductor hallucis; 3, flexor brevis digitorum; 
4, tendon of flexor longus hallucis (Richer) . 



Fig. 259. — Second layer of muscles of 
foot; I, Tendon of flexor longus hallucis; 
2, tendon of peroneus longus; 3, acces- 
sorius; 4, tendon of the flexor longus digi- 
torum and lumbricales; 5, flexor brevis 
minimi digiti (Richer). 



tendons of the flexor longus hallucis (Fig. 258, 4), the flexor 
longus digitorum (Fig. 259, 4), and of the tibialis posticus, passing 
around the inner malleolus, and binding together by its expanded 
tendon all the bones of the tarsus except the astragalus. The 
tibialis anticus (Fig. 261, i) also helps by lifting the proximal 
end of the first metatarsal bone. These muscles, by their 
action, all lift the inner side of the foot and draw together the 
limbs of the anteroposterior arch, like the string of a bow. 

The lateral arch of the foot (Fig. 262) is imperfect, in that its 



FLAT-rOOT AND CLUB-FOOT — TREATMENT BY EXERCISE 373 



support is at the outer side only, the weight being borne by the 
OS calcis, the cuboid, and the fifth metatarsal. It is only one-half 




Fig. 260. — Deep layer of muscles of the 
foot: I, Peroneus longus; 2, interossei; 3, 
flexor brevis hallucis; 4, 5, adductor hallucis 
(Richer). 




Fig. 261. — The tendons that support the 
arch: i, Tibialis anticus passing under an- 
nular ligament (2); 3, soleus; 4, flexor 
longus digitorum; 5, tibiaUs posticus; 6, 
flexor longus hallucis; 7, tendo Achilles; 
8, abductor hallucis (Richer). 




the arch completed by placing the feet together. The arch rises 

upward and inward, and its free, unsupported edge is represented 

by the astragalus, the navicular, the internal 

cuneiform, and the first metatarsal. The 

lateral arch is supported principally by the 

tendon of the peroneus longus (Figs. 259, 2; 

260, i), crossing the foot diagonally from 

the cuboid to the internal cuneiform, and by 

the ligaments binding together the adjacent 

bones; it also receives some support from the 

tibiahs anticus. 

The body weight is transmitted through the tibia to the 
astragalus. This pressure on the keystone tends to spread the 
members of the arch, and, in so doing, to stretch the long and 
short plantar ligaments. As the structures yield the inner side 
of the foot comes down, and the lateral arch shares in the flat- 
tening process. It is, however, the unsupported part of the 



Fig. 262. — Lateral 
arch. Pull of pero- 
neus longus. 



374 EXERCISE IN EDUCATION AND MEDICINE 

arch that is chiefly affected, and the flattened instep also pro- 
jects inward, causing the inner Hne of the foot to bulge at its 
center, the outline becoming convex instead of straight or 
concave. Pressure is thus put on surfaces of the bone that are 
not accustomed to it, and severe crippling pain is one of the 
most common results, while corns and callosities add their dis- 





Fig. 263. — Direction of tlic body weight on Fi;j;. 204. — Transferring the direction of 

the unsupported part of the hiteral arch. the body weight to the outer side, or sup- 
ported part of the arch, by raising the inner 
side of the shoe. 

comfort to the unnatural pressure antl friction of the abnormal 
position. 

A typical case of flat-foot would then show a turning out of the 
line of the heel (Fig. 267), a convexity of the inner contour of the 
foot,and a concavity of its outer margin. A tracing of the foot would 
show no instep (Fig. 266, a). While this deformity is sometimes 
caused by paralysis of the posterior tibial group of muscles, or by 
the peroneal group, and is also the result of traumatism in broad 



FLAT-FOOT AND CI.UU-FOOT — TREATMENT BY EXERCISE 



375 



jumpers whose arch is broken down by the shock of kinding on 
hard ground, still the great majority of cases are what might be 
termed static, and are found in 
nurses, clerks, waiters, barbers, 
motormen, and all others whose 
long hours of continual standing 
keep the muscles and ligaments 
of the foot constantly ui)on the 
strain. The pernicious habit of 
standing with the toes turned out 
always makes it worse. It is also 
found in the veryfat, whose weight 
is too much for their ligaments. 
It is a comparatively frequent 
condition, and is usually associ- 
ated with other deformities of the 
apparatus concerned in support. 
Bernard Roth, in his series of 
looo cases of scoliosis, found it 
in 76 per cent, of them. In an 
examination of 1000 supposedly 
normal students I have found 

it in 217 cases. Among men applying for military service in the 

United States, about 3.4 per cent, are rejected for this cause. 

^0 1^0 These figures, however, do not-in- 

^^ft 2K^ elude men who are suffering from 

^^^ BIm^ flat-foot, but who are rejected for 

^V ^^^/ some major trouble. An applicant 

^B Ljl / suffering from hernia and flat- 

^H ^^1 f<><^t would be rejected, but the 

^^ ^^ cause of his rejection would be 

given as hernia. Lovett has found 

many cases among hospital nurses, 

who are peculiarly susceptible to it. 

The symptoms are very varied. A consiflerable degree of 

flat-foot may be present without causing much irritation, and 




I' if,'. 2O.S. l''lat-fo<)l (I'owlcr). 



A 

Fig. 266.— Print 
foot-sole (a) and of 
(11) (All)ert). 



of a normal 
flat-foot sole 



376 



EXERCISE IN EDUCATION AND MEDICINE 




again great pain may be caused by comparatively slight degree. 
Painful points are found at the attachments of the calcaneo- 
navicular ligament, the anterior end 
of the OS calcis, at the attachments 
of the short plantar Hgament, and at 
the base of the first metatarsal, while 
there may be shooting pains up the 
calf of the leg. The heels, as seen 
from the back, are characteristic, the 
line of the tendo Achilles, with the 
ball of the heel, usually making a 
sharp turn outward (Fig. 267). This 
is emphasized when the weight is 
borne on the foot. It may very often 
be detected by examining the shoe 
only, the fiat-footed patient tending 
to wear down the inner side of the 
heel and sole. 

A patient should be examined 

with the foot uncovered, walking 

backward and forward in order 

that the foot may be seen in action 

from all positions. The inner line of the foot, and the extent to 

which the instep is destroyed, should be noted. 

Cases are best recorded by making a print of the weight-bear- 
ing foot as follows: Prepare a solution of perchlorid of iron in 
glycerin. By means of a brush or cotton-wool wrapped on a small 
stick paint the sole of the foot with this solution, place the 
patient's foot on a sheet of paper, having him put the full weight 
down upon it. Brush the resulting print with a solution of tannic 
acid, and the tracing becomes black and legible, and forms a 
convenient means of following the progress of treatment. 

The appearance of the foot is not the only thing to be consid- 
ered, for the arch of a baby's foot has an appearance of flatness, 
because the pad of fat which occupies the arch is not absorbed 
until the child has begun to walk. 



Fig. 267. — Showing one of the 
first signs of flat-foot. The out- 
ward deflection of the lower end of 
the tendo Achilles when weight is 
put on the foot (E. H. Ochsner). 



FLAT-FOOT AND CLUB-FOOT — TREATMENT BY EXERCISE 377 

Flat-foot is liable to be confused with tenosynovitis, the pains 
from corns and callosities, and with neuralgia of the metatarsus 
or the tendo Achilles. The most frequent mistake in diagnosis 
is rheumatism, which seldom affects the foot alone, although I 
have seen it in one case in which the diagnosis of rheumatism 
was confirmed by its subsequent appearance in other joints. 

Although not a fatal disease, it is the cause of great pain and dis- 
comfort, and sometimes the patient becomes chair or bedridden. 

Treatment must support the arch and correct the deform- 
ity, so that no treatment is complete which does not develop 
the structures involved in the normal preservation of the arch. 

The market is flooded with patent devices for the support of 
the broken-down arch, but no mechanical treatment should be 
employed unless it accurately fits the individual case. More harm 
than good has been done by the use of ill-fitting and imperfectly 
supporting foot-plates. A foot-plate or bandage of any kind 
must be looked upon in the light of a splint, to be discontinued 
as soon as possible, and to be used only in conjunction with 
other means of treatment. 

In most cases treatment by exercise should be begun by 
manipulation, stretching and massaging the foot; but where the 
pain is too severe, it may be necessary to give the foot a com- 
plete rest for two weeks or more by incasing it in a plaster 
bandage. When tenderness is sufficiently lessened, the following 
manipulations and active exercises may be started: 

Exercise I. — Patient sitting, leg extended and supported just 
above the ankle. Grasp the right foot just above the ankle with 
the left hand. Place the right hand on the sole of the foot. With 
the thumb pointing toward the toes grasp the foot firmly, cir- 
cumduct the foot slowly in the following order: (i) Extension; 
(2) inversion; (3) flexion; (4) eversion. 

This should be done with as much force as can be used without 
producing pain, and repeated up to about thirty times. Each 
part of the movement should be separated from the next by a 
distinct pause. When this has been learned it may be replaced 
by the active movement. 



378 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. 268. — Extension of tlie foot. 




Fig. 270. — Flexion of the foot. 



Exercise II. — Foot in the same position. Circumduction in 
the same order without assistance. Repeat fifty times. 



FLAT-FOOT AND CLUB-FOOT — TREATMENT BY EXERCISE 379 



The operator should supervise this movement and encourage 
the patient to make the extension and inversion as complete as 
possible, so that the long and short flexors and tibial muscles may 
have complete contractions at each movement (Figs. 268-271). 




Fig. 271. — E version of the foot. 





Fig. 272. Fig. 273. 

Exercise III. — Patient standing with toes in, heels out, and 
about 12 inches apart (Fig. 272). Rise on the toes and press 
out slowly (Fig. 273). Repeat fifty times. 



380 EXERCISE IN EDUCATION AND MEDICINE 

Exercise IV. — Patient standing, feet parallel and 6 inches 
apart. Raise the inner side of the foot, throwing the weight on 
the outer border. Repeat fifty times. 

This transfers the weight from the hgamentous support to 
the bony ridge of the outer edge of the foot (see Figs. 263 and 
264), and should be followed by — 

Exercise V. — Patient standing, feet parallel, weight resting 
on the outer side of the foot (Fig. 274). Walk forward and 





Fig. 274. — Walking on the Fig. 275. — As the knee is bent the forward part of the 

outer sides of the feet. foot is kept on the ground as long as possible. Twisting 

it downward and inward. 

backward fifty steps, keeping the feet parallel and forcing down 
the ball of the foot. 

This exercise is also valuable in throwing the weight of the 
body on the soKd part of the lateral arch, and is one that is often 
instinctively taken by patients to reheve the intolerable pain 
caused by the overstretching of the ligaments. 

Exercise VI. — Patient standing, feet 12 inches apart and 
parallel, knee bending and outward pressing (Fig. 275). 



FLAT-FOOT AND CLUB-FOOT TREATMENT BY EXERCISE 



;8i 




Exercise VII. — Patient standing, feet 6 inches apart and 
turned in as in Fig. 272. Rise on toes and walk forward and back- 
ward fifty steps, crossing the feet and keeping the toes turned in. 
. Exercise VIII. — Patient right lunge standing, neck firm. 
Forward bend with right knee bending until heel is forced from 
the floor, keeping the weight, 
on the outer side of the foot. 
Ten times. Repeat with the 
left (Fig. 276). » 

This exercises the lower 
back, thighs, and legs as well 
as the feet, and cultivates 
correct balance of the weight 
which is important. 

Exercise IX. — Patient 
yard standing, feet parallel, 
6 inches apart. Sway slowly 
forward and backward on 
heels and ball of the foot, 
chest active and chin in. 
This is a balancing exercise to get the proper relation of the 
thorax, abdomen, and hips in the bearing of the body weight. 
(See Figs. 143, 144.) 

Exercise X. — Raise the heel i inch from the ground and walk 
without bringing the heel down at all, as if the heel were painful. 

This exercise may be practised indefinitely, the patient 
walking for 100 yards without letting down the right heel, and 
then the next 100 yards without letting down the leift, or rais- 
ing the heels when crossing the street, or other plans that will 
readily suggest themselves. A little practice will enable him 
to walk in this way without limping or otherwise attracting 
attention. 

These exercises should be repeated daily, and in slight cases 
should be carried on for at least three months, whereas in severe 
cases they should be kept up as a daily routine for at least one year. 
In favorable cases this may be all that is required (Figs. 277- 



Fig. 276.- 



Lunge standing, knee bending, 
and heel raising. 



382 



EXERCISE IN EDUCATION AND MEDICINE 



280), but usually it will have to be combined with some form of 
specially designed shoe, with strapping or other mechanical sup- 





Fig. 277.— M. March 6. 





Fig. 278. — M. April 3. After one month's exercise only. 

port to retain the gain and to prevent the original cause of the 
deformity from undoing the corrective work of the exercises. 



FLAT-FOOT AND CLUB-FOOT — TREATMENT BY EXERCISE 383 



The shoe should present a straight inner Hne, allowing per- 
fect freedom to the toes, and high heels should be avoided. 

The heel should be low and broad, and should project for- 
ward on the inner side to help in the support of the arch (the 
Thomas heel). A broad shank and stiff counter should be 
added, although a counter always sags with wear. 

The "ground gripper" shoe exaggerates the inversion of the 
foot and is most comfortable and efficacious, although not very- 
beautiful. It has a flexible shank. 





Fig. 279. — A. M. November 4. Before be- 
KinniiiK treatment. 



Fig. 280. — A. M. March to. After exer- 
cise treatment for five months. 



An excellent shoe was devised by Small, of Boston, in 
which the rigid shank from the heel to the sole of the shoe is 
replaced by one that is flexible, allowing free movement to the 
whole foot and yet giving adequate support. The inner side 
of the heel and sole may be thickened, or a cork insole may be 
made to lift the inner side of the foot. This places the thrust of 
the body weight outward toward the supported side of the foot- 
arch and lessens the strain on the ligaments. 

Among the many rigid plates designed to support the foot, 
undoubtedly the best is the one described by Royal Whitman^^ 

^American Journal of Orthopcjedic Surgery, Oct., 1913. 



384 



EXERCISE IN EDUCATION AND MEDICINE 



(Fig. 281). A plaster cast of the foot is taken, and an iron plate 
is fitted to it, with bearing points at the head of the first meta- 
tarsal, under the heel, and behind the fifth metatarsal bone. 
From these bearing points the plate fits into the arch of the in- 
step, and may be trimmed to suit the convenience of the wearer. 




Fig. 281. — Whitman's plate to support the arch of the foot in flat-foot (Fowler). 

It is easily removable from the shoe, and does not press upon the 
foot except when it is bearing the body weight. 

A bandage which has proved exceedingly useful in the hands 
of Dr. E. H. Ochsner is described by him as follows: 

"I first select a good make of zinc oxid adhesive plaster in 
12-inch rolls. After measuring the patient's leg I mark off the 







— ^- -r^ 9—9 


/S. X OU. 








J'/yX /3 


Jfyx/^ 


j'4'xf/ 


J'^// 


j'A' X f 


3'6'xf 


j'/yxs 




,- 


, 


1/ 


,, 


7i. V / 


^p x' :f 


?■> )t f 


'/j y^ 











Fig. 282. — Showing how the zinc oxid plaster is marked oS preparatory to cutting strips 
for strapping an adult male patient's foot (E. H. Ochsner). 

adhesive strips according to the size of the extremity. For the 
purpose of strapping a male patient of ordinary size I mark off 
7 strips \ inch wide by 32 inches long, with a cross line at its 



FLAT-FOOT AND CLUB-FOOT — TREATMENT BY EXERCISE 385 



middle; i6 strips | inch wide and 8 inches long; i piece 35 inches 
by 13 inches; i piece 3^ by 12 inches; i piece 3^ by 11 inches; and 
4 pieces 3^ by 8 inches (Fig. 282). I do this as a matter of con- 
venience, and in order to prevent the unnecessary handling of 
adhesive plaster after the facing is once removed. 

"The heel of the patient's foot is now placed on the chair, with 
the knee flexed, and a short, hard, roller bandage is looped around 
the foot. I direct the patient to draw the foot upward, thus 
placing the foot at a little less than a right angle to the leg, 
moderately inverted and ad- 
ducted, the patient holding the 
bandage himself. 

"I now put the middle of the 
32 by I inch strip over the bot- 
tom of the heel, about i inch 
from its posterior border, one-half 
up the outer surface of the leg, 
without tension, and the other up 
the inner surface of the leg, as 
tight as I can. I then place one 
of the shorter narrow strips on 
the inner surface of the foot, 
parallel with the sole, and on the 
outer surface. The remaining 
narrow strips are placed in the 
same manner, each one slightly 

overlapping its predecessor. When these are all in place I 
cover them with the 7 remaining strips, beginning at the upper 
part of the leg, as illustrated in Fig. 283. These strips will 
remain in place and be effective from four to eight weeks, when 
they may be removed with benzin. The foot is washed with 
soap and warm water, carefully dried, and it is again restrapped 
the following day. A foot may require from two to ten strap- 
pings, and the relief is almost immediate. This strapping tends 
to supinate the foot and relieve the pain by relaxing the muscles 
and supporting the Hgaments." 




Fig. 283. — Showing arrangement of 
the 3|-inch strips over the narrower 
strips (E. H. Ochsner). 



386 EXERCISE IN EDUCATION AND MEDICINE 

I have quoted this at length, because the best results can be 
obtained by a combination of this treatment with exercise. 
From the perishable character of the plaster, one is less apt to de- 
pend upon it alone, as is so frequently done with the metal 
fiat-foot supports, while the danger of injury to the foot from 
bruising and formation of callosities arising from the use of 
plates unskilfully applied is completely avoided. 

A fiat-foot plate or bandage must, as already emphasized, be 
regarded in the same light as a crutch, cane, or spHnt would be 
for a joint unable to bear the strain of use, and it is to be dis- 
carded when the normal strength has returned and undue irri- 
tabilit}^ has disappeared. 




Fig. 284. — Manipulation for talipes equinovarus. 

To continue the support after the indications for its use have 
disappeared is to hamper the normal functioning of the muscles 
and ligaments of the foot and leg. 

The contraction of the plantar fascia, so frequently seen at 
birth, produces the opposite deformity from that just described, 
and the conditions of talipes equinus and varus and their com- 
bination in varying degrees can be greatly improved, and in many 
cases completely cured, by stretching manipulations of the 
child's foot. These should be taught the mother, and she should 
perform them at frequent intervals during the day, carrying the 
pressure to the point of pain. The two following are directed to 
correct the equinus, and the third is for the varus. 



FLAT-POOT AND CLUB-FOOT — TREATMENT BY EXERCISE 387 

Exercise I. — Grasp the right ankle with the right hand, 
thumb toward the foot. Place the left hand on the sole of the 
foot, with the ball of the thumb on the ball of the foot. Grasp 




Fig. 285. — Manipulation for talipes equinovarus. 

the foot with the left hand and press the foot upward in dorsal 
flexion, twist the foot inward and outward as far as possible, 
relax, and repeat twenty times (Fig. 284). 




Fig. 286. — Manipulation for talipes equinus. 

Exercise II. — Grasp the ankle with the right hand as in 
Exercise I, place the left hand fiat on the sole of the foot, press 



388 EXERCISE IN EDUCATION AND MEDICINE 

the foot upward into dorsal flexion, relax, and repeat twenty 
times (Fig. 285). 

Exercise III. — Place the foot, outer side down, on the 
knee, grasp the heel and ball of the foot and press downward, 
stretching the contracted plantar fascia and ligaments. Repeat 
twenty times (Fig. 286). 

In certain cases a corrective bandage or boot is necessary. It 
should be worn in the intervals of treatment by manipulation. 

Very severe cases in infancy usually require operative inter- 
ference as well, and in adults, where the bones have become 
adapted to the distorted posture, surgical treatment will always 
be necessary. Th€ manipulations described above are especially 
adapted to mild and moderate cases in infants. 



CHAPTER XXII 

THE CAUSE AND TREATMENT OF ROUND BACK, 
STOOPED, AND UNEVEN SHOULDERS 

If an infant be placed upon its back, it will lie with a straight 
spine and thighs flexed to nearly 90 degrees. If it l^c placed in a 
sitting posture the thighs remain Hexed and the spine shows a 
single convex backward curve involving its entire length, but in 
the standing posture the right angle between the trunk and 
thighs must be extended to a straight line, and this is effected 
by a c()m])romise between the lumbar spine and the hip-joint, 
both yiekiing part of the way. 

When the hip-joint is extended the iliopsoas muscle is 
stretched, though this extension is not sufficient to preserve the 
convex backward curve of the sitting posture. A sharp forward 
curve develops in the lumbar region. The anterior vertebral 
ligaments are stretched, the intervertebral disks thicken ante- 
riorly, and the erector spime muscle becomes active and power- 
ful. This curve, which is very marked in young children, gives 
them their characteristic "pot-bellied" appearance, and is ac- 
companied by a localization of the compensating backward curve 
to the dorsal region, and by the formation of a third in the^ cer- 
vical region, showing the same forward convexity as the lumbar 
curve. These three curves are physiologic and are always found 
in the adult normal spine, and it is their exaggeration or imper- 
fect development that will be considered in this chaj^ter. 

The shoulder girdle is constructed to permit the widest 
range of movement with the utmost lightness of structure, but 
the pelvic girdle, whose chief office is that of support, is lirm 
and archlike, with powerful ligaments, heavy bones, and scarcely 
perceptible movement. The entire weight of the head, neck, 
upper extremities, and shoulders hangs ui)on the flexible and 

389 



390 EXERCISE IN EDUCATION AND MEDICINE 

growing spine during the standing and sitting positions, and the 
muscles that steady the spinal column rapidly become fatigued 
when thus kept on the strain and allow the shoulders to droop 
forward, bending the neck and back with them. The resulting 
deformity is called stoop shoulders, slant shoulders, round 
back, faulty attitude, kyphosis, or bowed back, and when the 
deviation is to the side, either right or left, it is known as scoliosis, 
or lateral curvature. 

The condition of round shoulders can be determined only 
after the normal standing attitude is clearly defined in the mind, 
and deviations from this normal attitude can then be noted and 
accurately described. 

In the normal standing position the long axis of the head, 
trunk, and leg will form a straight line. A plumb-line should 
touch the dorsal spine and the sacrum at their greatest projec- 
tion. It should be the attitude in which there is the least strain, 
in which the head is erect and balanced, relieving the neck 
muscles; the shoulders should be back so that their center is 
distinctly posterior to the center of gravity, the chest held high, 
and the abdomen fiat. The pelvis should be inclined forward so 
that the axis from the promontory of the sacrum to the top of 
the pubic bones is 30 degrees downward and forward from the 
horizontal, the knees straight, and the center of gravity in front 
of the ankle-joints, as determined by Reynolds and Lovett in 
their two hundred observations on balance. 

Lovett determined the standard normal standing posture by 
marking the following points — (i) the external malleolus, (2) 
the head of the fibula, (3) the great trochanter, (4) the fourth 
lumbar spine, (5) the seventh dorsal spine, (6) the spine of the 
vertebra prominens, and (7) the middle of the mastoid process, 
and having the patient stand with the malleolus opposite an 
upright standard, the relative position of each of these points 
being noted (Fig. 287). 

A composite of seventy-two normal boys (Greenwood) be- 
tween the ages of fifteen and nineteen years shows the follow- 
ing tracing (Fig. 288). 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



391 



By means of this standard faulty attitudes are classified 
into (i) round back, showing a general curve backward with- 
out lordosis (Fig. 291, b); (2) round hollow back, with the back- 
ward projection greatest in the middorsal region and with pro- 
nounced lordosis, the forward projection of the head bringing 




6'4, 



Fig. 287. — Lovett's apparatus for 
measuring variations from normal atti- 
tude in the anteroposterior plane. 



Fig. 288. — Compos- 
ite curve of seventy- 
two normal boys 
(Greenwood). 



Fig. 28g. — Curve of 
young adult female of 
good carriage (Lovett) . 



the upper three measurements almost in line; (3) forward dis- 
placement of the shoulders, the scapulas and clavicles being 
displaced independently of the condition of the spine. This 
condition may exist either with or without a rounded back. A 
graphic tracing of these curves may also be obtained by the panto- 



392 



EXERCISE IN EDUCATION AND MEDICINE 



graph method, described in the following chapter (Fig. 290), or 
by the rods and frame used by Lovett (Journal A. M. A., March 
26, 1910). 

From the standpoint of treatment, these deformities may be 
classified into flexible and resistant. During the years of growth 
posture will usually take care of itself if constant change be 

allowed, for change is in- 
stinctive and automatic in 
the child and his varied 
activities may be trusted 




Fig. 2go. — Making a tracing of the antero- 
posterior curves of the spine by the pantograph 
method. 



Fig. 2QI. — Anteroposterior trac- 
ings of the spine: a, Correct posture; 
b, first type of round back; c, ex- 
treme resistant round back in a 
young girl. 



to lead him along normal lines. If from inherent weakness 
or confinement of school life without the relief of games and 
play this normal development be hindered, the spine is one of 
the first parts of the anatomy to reveal it. 

The causes of round shoulders are then those general condi- 
tions that produce muscular or constitutional weakness, like 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



393 



rapid growth, overwork, bad air in schools or home, acute ill- 
ness, myopia uncorrected by glasses, poor hygiene at home, or 
general lack of exercise, and, secondly, occupations that demand 
long-continued fixation during the period of growth. Among these 
may be mentioned the use of ill-fitting school furniture, long- 
continued writing and drafting, or work with the microscope; 
in fact, the requirement of any 
fixed position for more than a 
few minutes at a time in a 
young child. His restlessness 
in school is his only means of 
protest, and is the object of 
much misapplied correction 
by those school teachers who 
believe that quietness and 
goodness are synonymous. 
The third cause, more direct 
than either of the others, is 
the wearing of clothing sup- 
ported by suspenders bearing 
on the points of the shoul- 
ders, tending to pull them 
downward and forward. 

It is a very frequent de- 
formity among school chil- 
dren, and it occurs in almost 
20 per cent, of university 
students uncompHcated with 
other postural defects. Where 
a greater deviation is present, 
such as lateral curvature, a 

note is usually made of the scoliosis only, so that its occurrence 
is more frequent than these figures would indicate. It is fre- 
quently discovered in girls about the age of puberty, when espe- 
cial attention is apt to be paid to their figure and carriage. 

Round shoulders are not likely to be outgrown, and patients 




Fig. 2g2. — Showing a common underwaist 
with the straps bearing upon the outer part 
or movable part of the shoulders (Goldth- 
wait) . 



394 



EXERCISE IN EDUCATION AND MEDICINE 



usually become permanently and structurally set in the faulty 
posture, with flattened chest walls and distorted figure. 

An examination of the back should begin by testing the 
spine's range of movement forward, backward, and lateral. 
The patient should then take his habitual standing position, 
which he should retain until his self-consciousness abates. The 
overcorrected standing posture should then be tried. This may 
be done by having him force the chest forward and upward to 
touch the surgeon's hand, held just far enough in front of and 




Fig. 2g3. — Correct support of clothing. The weight comes on the root of the neck instead 
of the shoulder-tips (Goldthwait). 

parallel to the chest wall to bring the contour of the thorax 
directly above that of the abdomen. This maneuver should 
always be done before a mirror, that the patient may associate 
the sensation with the picture of the correct posture, and it will 
take time and patience on the part of both. He should then be 
taught to take several long breaths without relaxing the pose. 
If the child be placed face downward, with the arms at right 
angles to the body, flexibility of the shoulders can be tested by 
attempting to force the arms back of the middle line of the 
body. They should then be lifted upward beside the head and 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 395 

forced backward. During these movements the whole spine 
should be narrowly observed. In resistant cases the arms cannot 
be brought behind or even up to the median plane of the body. 
It can only be simulated by hollowing the lower part of the back 
and protruding the abdomen, flattening the chest, and project- 
ing the chin. In non-resistant cases there is usually a general 
relaxation of the ligaments, as shown in hyperextension of the 
elbows and knees, as well as of the spinal ligaments, and if the 
patient can voluntarily assume a correct position the case may 
be pronounced non-resistant. In resistant round shoulders and 
forward displacement, however, there is always more or less 
structural change, involving a forward curvature of the upper 
part of the scapula, a shortening of the coraco-acromial ligament, 
or, according to Fitz, a tightness of the serratus magnus muscles 
associated with weakness of the rhomboids and trapezius. 

By adequate treatment all cases are capable of improvement, 
and almost all, except the most resistant, are capable of complete 
cure. Exception must be made in the case of those congenital 
cases where they have never adapted themselves to the upright 
position, where all the ligaments are relaxed, where the ptosis 
of the abdominal organs indicates the lack of tonicity of the 
system, and where the vitality is so low that the necessary exer- 
tion is too exhausting to the patient. In such cases additional 
muscular effort is translated into pain and backache. Any 
irritable condition of the spine should be looked upon with 
suspicion, and girls and women often require the services of a 
gynecologist as well. All such cases should be given a rigid and 
thorough examination and kept under observation for weeks 
before severe exercise is prescribed. 

Before beginning treatment it is important to differentiate 
between the flexible and the resistant cases, and between both 
and arthritis where pain is a prominent symptom. 

Treatment may be divided into (i) hygienic, (2) exercise, 
and (3) stretching. 

Hygienic. — The patient should have the best available sur- 
roundings as to light, air, and food, because, as a rule, they are 



396 EXERCISE IN EDUCATION AND MEDICINE 

underdeveloped muscularly and have not the constitutional 
resistance nor the will-power of the average child. The muscle 
fatigue that comes on from strained fixed positions among school 
children must be avoided by every available means. School 
furniture should be adjusted to prevent undue flexion of the 
back and forward bending of the head during reading and 
writing. Errors of refraction should be corrected. The clothing 
should be examined, and when found to be supported from the 
tip of the shoulders the garments should be altered to bring the 
pressure in toward the root of the neck instead of out on the 
shoulders (Fig. 293). 





Fig. 294. — Outline drawing of a bad cor- Fig. 295. — Outline drawing of a good 

set applied to a model (Reynolds and Lov- corset applied to a model (Reynolds and 
ett). Lovett). 

Miss Bancroft has pointed out ("The Posture of School 
Children") that the cut of most ready-made clothing causes 
pressure on the back of the neck and tip of the shoulders, con- 
stantly tending to produce this deformity, while the investiga- 
tions of Reynolds and Lovett on balance throw interesting light 
on the corset and high-heeled shoe as articles of dress. 

They divide corsets, according to their effect on posture, 
balance, and backache, into good and bar^ The bad corset is 
long behind, especially at the top, short in front, especially at 
the bottom. It exerts its greatest pressure at the waist, and at 
the top and bottom is capable of exerting pressure only against 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



397 



the wearer's back (Fig. 294). It has a strongly marked sacral 
curve, but is otherwise straight in the back and is highly in- 
curved at the waist in front. It moves the center of gravity 
of the body back, throwing the hips far back of the normal, and 
thus giving the illusion of forward shoulders (Fig. 297). The good 



Fig. 297. — Position induced by bad cor- 
set in dotted outline; normal, in solid line. 
In this instance the shoulders are thrown 
forward of the normal and the hips back 
(Reynolds and Lovett). 



Fig. 296.— Position induced by bad cor- 
set in dotted outline; normal, in solid line. 
In this instance the shoulders are thrown 
back of the normal a little, but not so 
much as the hips. On this and all fol- 
lowing records the solid vertical indicates 
the original position of the center of grav- 
ity; the dotted vertical, the induced posi- 
tion (Reynolds and Lovett). 



corset is short behind, especially at the top, and long in front, 
especially at the bo+tom. It fits tightly around the pelvis be- 
tween the iliac crest and trochanters and decreases regularly 
in pressure to its upper edge, where it is very loose, especially 
behind. It is considerably incurved at the waist line, at the 



398 



EXERCISE IN EDUCATION AND MEDICINE 



back and sides, but shows no waist curve in front (Figs. 295, 298), 
It moves the center of gravity uniformly back. The rules for 
construction are given in detail, and the cHnical test is comfort 
to the wearer and the approximate outline shown in Fig. 295. 



A 



Fig. 298. — Position induced by good 
corset in dotted outline. Normal, in solid 
line. The apparent flattening of the lumbar 
curve in the dotted line is due to the bulg- 
ing of the soft tissues through the open 
space at the back of the corset (Reynolds 
and Lovett) . 



Fig. 299. — Record of the normal posi- 
tion and that induced by high-heeled 
shoes: the normal in solid line, the in- 
duced position in dotted line (Reynolds 
and Lovett). 



High-heeled shoes tip the body back as a whole without 
making any appreciable change in the lumbar curve (Fig. 299), 
and so exert less influence on the production of abnormal antero- 
posterior curves of the spine than has been placed to their dis- 
credit. A patient in a bad corset will be more comfortable with 
high heels than without them, because they displace the center 
of gravity backward. Balance is maintained by the action of 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



399 



the muscles of the neck, back, and calf, and anything that will 
relieve this strain, especially where the muscles are weak, will 
come in the nature of a relief. The bad corset does this only 
apparently, for the work of the spinal muscles is really increased 
and the backache and postural troubles in consequence aggra- 
vated. 

Exercise. — In the treatment by exercise, expansion of the 
lungs by deep breathing to round out the flattened chest should 





Fig. 300. — Correct standing posture. 



Fig. 301. — Incorrect standing posture. 



be emphasized. These exercises are described fully in Chapter 
XXVII. The correct standing position and carriage of the 
body should be continually and persistently insisted upon. This 
must not be done by contracting the retractors of the shoulders, 
but rather by bringing in the chin and forcing the thorax forward 
and upward (Fig. 300), as already described. The muscles of 
the upper back must be strengthened to carry out their function 
of support, and the abdominal muscles must be developed and 



400 



EXERCISE IN EDUCATION AND MEDICINE 



trained to overcome the weak and relaxed carriage of the pro- 
tuberant belly. The following exercises would constitute a 
daily prescription : 

Exercise I. — Patient standing in his habitual faulty po- 
sition (Fig. 302). Place the hand about one inch in front of 
the sternum and tell him to raise the chest and shove it forward 
to touch the hand without swaying the body. In doing this at 
first he will try to draw the shoulders back, contracting the 



Fig. 302. — Diagram showing the relation 
of the head, thorax, and pelvis in the incor- 
rect standing position. 



Fig. 303. — Diagram showing the relation 
of the head, thorax, and pelvis in the cor- 
rect standing position. 



trapezius and rhomboids. This fault must be overcome at the 
very beginning, and the shoulder muscles must be kept relaxed. 
Gradually increase the distance to which he can bring the chest 
forward, repeating it again and again until he can take the 
position without difficulty and without contracting the muscles 
of the back. While in this position make him breathe deeply 
five times and then relax. This should be done before a mirror, 
so that he will recognize the feeling of the correct posture and 
associate it with the proper attitude as seen in the glass. He 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



401 



should then try to take it without looking at the mirror. This 
posture should be drilled into him until it becomes habitual 
and until he can maintain it without discomfort. 

R. J. Roberts, of Boston, was accustomed to tell his young men 
to press the back of their neck against their collar-button, con- 
sidering this as the keynote of the position. In whatever way it 





304- 



Fig. 305. 



is accomplished, the object is to get the proper relation between 
the thorax and the pelvis. 

After repeating Exercise I twenty times, take Exercise II. 

Exercise II. — Arms forward raise, upward stretch, rise on 
tiptoes, inhale. Sideward lower, slowly press the arms back and 
exhale (Figs. 304, 305, 306). 



402 EXERCISE IN EDUCATION AND MEDICINE 




Fig. 306. 





Fig. 307. 



Fig. 308. 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



403 



This exercise when done correctly expands the chest, bringing 
in all the extensors of the back and the levators of the shoulders. 
Exercise III. — Patient standing, arms downward and back- 
ward, fingers interlocked and palms outward (Fig. 307). Extend 
the neck, roll the shoulders backward and forearms into supina- 
tion, the palms being first in, then down, and then out (Fig. 308). 
Reverse to starting position and relax. 

This exercise is valuable for projecting the chest forward, 
stretching the shortened ligaments and drawing in the abdomen. 

Care should be taken to have 
the chin pressed backward 
when the arms are brought 
downward and turned out- 
ward. In resistant cases, 
where this exercise cannot be 





Fig. 309. 



Fig. 310. 



done with the fingers interlocked, a handkerchief tied in a loop 
may be substituted and held in the fingers (Fig. 372). 

Exercise IV. — Patient standing with the arms at the sides. 
Arms sideward raise, upward stretch, inhale, forward bend and 
rise. Arms sideward, lower, exhale (Figs. 309, 310). 

In this exercise the lungs are filled when the chest is in the 
most favorable position for expansion. The breath is retained 
when the trunk is flexed, forcing the air into the cells of the 



404 



EXERCISE IN EDUCATION AND MEDICINE 



lungs under pressure. The bending and rising bring into power- 
ful action the extensors of the back and neck and the retrac- 
tors of the shoulders. 

Exercise V. — Patient lying prone upon a couch with the feet 
strapped or fixed by an attendant. Hands clasped behind the 




Fig. 311. 

head. Raise the head and extend the spine, pressing the elbows 
backward (Fig. 311). Relax. 

This exercise is a severe one on the extensors of the back and 
the retractors of the shoulders, and should be followed by a 
deep breathing exercise (Fig. 312). 




2. — Deep breathing exercises introduced between two extension movetnents. 

Exercise VI. — Patient lying in a prone position, arms at the 
sides. Raise the head (Fig. 313), bringing the arms forward 
(Fig. 314). Imitate the breast stroke in swimming (Fig. 315). 

In this exercise the erector spinae is kept in static contrac- 
tion, while the retractors of the shoulder are alternately con- 
tracted and relaxed. 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



405 




Fig. 313- 




Fig- 314- 




Fig. 315- 



Stretching exercises that require the services of an assistant, 
or a machine designed for the purpose, should be associated 
with these voluntary movements. Sylvester's method of artificial 



4o6 EXERCISE IN EDUCATION AND MEDICINE 

respiration (Figs. 411, 412) may be employed with good effect, 
the upper dorsal region being supported by a hard pillow, the 
surgeon pulling at the end of the upper movement, stretching 
the thorax to its utmost. The intercostal machine (Fig. 316) is 
invaluable for securing the same kind of movement. Zander's 
machine, the tower (Fig. 317), straps the shoulder backward and 
forces the rest of the body, imitating closely the movement and 




rig. 316. — Triplicate chest weight, overhead or intercostal attachment. 

rhythm of ordinary respiration. The quarter-circle (Fig. 318) 
is another gymnastic machine designed to give breathing exer- 
cise with the body held in an overcorrected position. Taylor's 
spinal assistant (Fig. 319) produces the same effect by suspend- 
ing the weight from the arms with accented pressure on the 
dorsal region, either from behind, forward, or laterally, as shown 
in the illustration. 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



407 



The main value of these stretching movements is on the 
ligaments rather than on the muscles. 

In slight cases of round shoulders the strapping described by 
Goldthwait to draw the shoulders backward is of real value. It 
is composed of firm webbing, i inch wide, carried as a loop 
around each shoulder, the bands crossing in the back and being 




Fig. 317. — The "Tower," for respiratory movements. The shoulders are held firmly, 
while pressure is applied to the back. 



attached to the belt of an ordinary stocking supporter. The 
attachment of the shoulder-strap to the belt should be at the 
side directly over the stocking straps, and the belt should be 
worn about the hips and not about the waist as is usual. The 
straps should be sewed where they cross at the back over the 
angles of the scapulae, but should not be sewed where they cross 
in the mid-line. This allows body movements both to the side 



4o8 



EXERCISE IN EDUCATION AND MEDICINE 



and forward without straining upon the straps or changing the 
position of the belt level. 

An ingenious device for a similar purpose is the invention of 
Jessie Bancroft, and has the approval of the American Posture 
League. It consists of a strip of elastic webbing attached to the 




Fig. 318. — Quarter-circle (Spalding). 

coat between the shoulders. It exerts gentle tension whenever 
they come forward. 

For more resistant cases, where very active stretching is 
necessary, Lovett's apparatus is the best. It consists of an oblong 
gas-pipe frame. Hinged to this near the middle is another sec- 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



409 



tion of gas-pipe, of the same shape and size as the upper half of 
the frame. To this movable section is fastened at right angles a 
gas-pipe bridge, rising about 18 inches above it and movable on 
it (Fig. 320). When prepared for use, two strips of webbing, 
lying one over the other, run from each of the two buckles at the 
bottom end of the frame. The lower pair are tightly drawn and 
run through buckles at the upper end of the movable section. 
The upper two are loosely fastened to the bridge. The patient is 




Fig. 319. — Taylor's spinal assistant for suspension and lateral pressure. 

laid face downward on the webbing strips, protected by a piece 
of sheet-wadding if uncomfortable. The thighs are flexed and 
the feet rest on the floor, so that the lumbar spine is flattened. 
Two pieces of webbing are placed over the middorsal region 
from side to side, tied to the lower non-movable frame on each 
side, thus furnishing the resistance for the straightening of the 
spine when the upper end of the movable frame is raised, carry- 



4IO 



EXERCISE IN EDUCATION AND MEDICINE 



ing with it the head and upper chest. After the patient is in 
place the upper part of the frame is lifted, the amount of force 
permissible being not beyond the point of mild discomfort. 
Several stretchings are made of a few seconds each, the mov- 
able part of the frame being let down to rest the patient. 




Fig. 320. — Apparatus for stretching round shoulders (modified from Lovett). 

Flexible round shoulders in most cases yield to exercise alone, 
extending over a period of three to six months of daily treat- 
ment, but it may be advisable to maintain the improvement for 
a time by means of some such simple brace as the one described 
by Goldthwait, although fixation without exercise is irrational 
and leaves the condition worse than it found it. 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 



411 



Some resistant cases will require stretching by the Lovett 
apparatus, and fixation in the corrected position combined with 
vigorous development of the muscles of the back and prolonged 
training in the corrected standing position. 

Occasional cases in which there is structural deformity have 
been treated by cutting the coraco-acromial ligament, but such 
cases are the exception and need not enter into the discussion. 

After active treatment has ceased the 
patient should be kept under supervision, 
reporting progress at least once a month 
for two years. 

It is the rule rather than the excep- 
tion to find associated with round shoul- 
ders some inequality in their height. In 
1000 consecutive examinations of sup- 
posedly normal young men the right 
shoulder was low in 104 cases and the left 
in 20, and tailors tell me that it is almost 
the rule to put extra padding in the right 
shoulder of coats for the sake of appear- 
ance. The causes of an irregularity, vary- 
ing from f to 2 inches, are sometimes 
difficult to disentangle, but the carrying of 
weights like school books and bad habits 
in sitting and standing are among the 
most potent. The position of the child 
sitting at the school-desk during writing 
favors it, since the left arm and shoulder 
are supported and the right lowered. 
Habitual standing with the weight on the 

right leg contributes to a good many cases, as will be seen in the 
description of scoliosis, but weights carried in the hand or pres- 
sure on the right shoulder are the most direct, and it is a common 
thing to see this deformity in soldiers after carrying the rifle and 
bandolier during long marches. Figure 321 shows a man, otherwise 
powerful, symmetric, and well developed, who acquired it in 




Fig. 321. — Lowering of 
the right shoulder from 
carrying a. rifle and pressure 
of a bandolier for two years. 



412 



EXERCISE IN EDUCATION AND MEDICINE 



two years' active military service, during which he had to make 

long marches with his rifle and cartridge belt pressing down on 

the right shoulder. 

The great specialization of some games in which the right 

arm is almost exclusively used is blamed for many cases. Fenc- 
ing, baseball pitching, and putting 
the shot are ready examples. 

In response to an inquiry sent 
to 2 1 men who had the left shoul- 
der lowered, only 3 acknowledged 
to left-handedness. 

The patient placed before a 
mirror can almost always assume 
the correct standing posture by 
voluntary muscular effort, but to 





Fig. 322. 



Fig. 323. 



him it does not feel normal or natural, and he quickly relapses 
if left to himself. 

In all straight and symmetric exercises the weaker side will 
get more work than the stronger, so that movements described 
for flat chest and round shoulders, ail of which bring in equally 
the muscles of both sides, would be of some value in these cases. 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 413 

It is necessary, in addition to this, to develop the upper part of 
the trapezius, the rhomboids, and the deltoid of the lower side 
and the latissimus dorsi and inferior part of the pectorals on the 
opposite side, and for this purpose the following exercises should 
be given for a lowered right shoulder: 

Exercise I. — Position, standing, arms down at the* side. Right 
arm forward raise; inhale (Fig. 322). Rise on tiptoes, stretch, 
sideward lower; exhale. The left arm should be shoved down- 
ward while the right arm is raised. 

This exercise brings into action the upper part of the trape- 
zius, deltoid, rhomboids, and serratus magnus of the right side, 
and the latissimus dorsi and lower part of the pectoralis major on 
the left. 

Exercise II. — Position, standing, arms down. Right arm 
sideward raise; inhale. Forward bend (Fig. 323), upward stretch, 
arm sideward lower, exhale. 

This exercise has the same effect as the first, with the addi- 
tional advantage of stretching the right side of the trunk more 
than the left as the body is bent forward. 




Fig. 324- 

Exercise III. — Position — prone — lying on plinth, right arm 
elevated, left arm forced downward. Extend the neck and back 
and relax (Fig. 324). 

Exercise IV. — Position, back to chest-weight floor attach- 
ment. Push upward with the right arm (Fig. 325). This brings 



414 



EXERCISE IN EDUCATION AND MEDICINE 



into action the right deltoid, the upper part of the trapezius, the 
rhomboids, and the serratus magnus of the right side. 

Exercise V. — Shrugging the right shoulder while holding a 
dumb-bell of 40 or 50 pounds (Figs. 326, 327) has the contrary- 
effect from continually holding the weight and keeping the 
muscles in tension. The intermittent contraction and relaxa- 
tion of the muscles tend to strengthen and develop them, and so 




Fig. 325- 



make them shorter when at rest, while continuous tensiort 
rapidly stretches them and destroys their tonicity. 

The putting up of a light dumb-bell, of 5 or 10 pounds, from 
the floor to arms' length above the head is another valuable 
exercise (Fig. 328). The nautical wheel (Fig. 255) turned coun- 
terclockwise, also will help to raise a lowered right shoulder. 
Hanging exercises, in which the weight is borne by the right arm 
with counterpressure on the left side, are of slight assistance in 
stretching the latissimus dorsi on the right side, but do not 



CAUSE AND TREATMENT OF UNEVEN SHOULDERS 415 

affect the upper part of the trapezius or the serratus magnus, 
both of which are relaxed in this position. 

The prognosis is good in all cases, if these exercises be fol- 
lowed persistently and faithfully in the form of a daily prescrip- 




Fig. 326. Fig, 327. Fig. 328. 

tion for three to six months. Most of the failures are caused by 
the carelessness of both surgeon and patient and the readiness 
of the tailor to act as their accomplice. 



CHAPTER XXIII 



SCOLIOSIS-ITS CAUSES, VARIETIES, DIAGNOSIS, 
AND PROGNOSIS 

The spine is protected against lateral deviation by three 
lines of defense of increasing strength — (i) the muscles forming 




Fig. 329. — The anterovertebral muscles, showing the iliopsoas and quadratus lumbo- 
riun in the lumbar region, and in the cervical the longus colli, the scalenus anticus medius 
and posticus on the right, and the sternomastoid on the left. 

an advanced mobile series of outposts brought into service in 
relays, powerfully but intermittently; (2) the Hgaments, more 
416 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 417 



resistant but less mobile, requiring long-continued and persistent 
attacks to overcome their normal protective action; (3) the 
bones, which may be compared to a citadel yielding to the in- 
fluence of deformity only after the other two lines of defense have 
long since been carried. 




^0^0 A, 



Fig. 330. — ^The superficial and deep layers of the spinoscapular muscles; on the right 
the latissimus dorsi and trapezius, on the left the rhomboideus major and minor and the 
levator anguli scapulas. 

The muscles acting upon the spinal column fall naturally into 
three groups — first, the anterovertebral, consisting of the psoas 
in the lumbar region, the three scaleni, the longus colli, and the 
sternomastoid in the cervical (Fig. 329); second, the spino- 
scapular in two layers, the trapezius and latissimus dorsi super- 
27 



4i8 



EXERCISE IN EDUCATION AND MEDICINE 



ficially, the rhomboids and levator anguli scapulas beneath them 
(Fig. 330); third, the spinal, consisting of the two posterior 
serrati, superior and inferior, and the erector spinae mass, thick 
and fleshy in the lumbar and cervical regions, but thin and ten- 
dinous in the dorsal (Fig. 331). Some of the deeper muscles well 




Fig. 331. — The erector spinae covered by the serrati postici, superior and inferior. On 
the left the attachments are shown diagrammatically. 



developed in the cervical and lumbar regions become ligamen- 
tous in the dorsal, illustrating the principle of regression, and this 
is significant of the relative amount of movement in the three 
regions. 

The most freely movable regions are most abundantly pro- 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 419 



vided with muscles, and it is to the analysis and application of 
their action that treatment of deviations by exercise must be 
directed. 

In childhood the spine is 
very flexible, and can be 
placed in almost any position 
or combination of positions. 
As age progresses this habit- 
ual posture becomes more 
and more fixed and the bones 
adapt themselves to the dis- 
tortion. 

Movements of the spine 
are flexion, extension, side 
bending, and torsion. 

Flexion in the spine takes place equally throughout its length 
(Fig. 333). Extension is lumbar and cervical. Even in contor- 
tionists the dorsal region remains almost straight (Fig. 332). 
Side bending takes place almost equally along the spine, with 




Fig. 332. — In overextension of the spine 
the bending takes place principally at the 
neck and loins (D wight). 




Flexion 




Complete 
extension 




Side bending 



Fig- 333- — Normal movements of the spine — cervical, dorsal, and lumbar (E. G. Abbott, 
Amer. Jour, of Orthopedic Surgery, July, 1913). 

accent at the twelfth dorsal and first lumbar. In side bending, 
with rotation from the erect position, the dorsal vertebrae follow 
the movement, slowly diminishing to the twelfth, but the lumbar 
vertebrae, and even the twelfth dorsal rotate in the opposite direc- 



420 



EXERCISE IN EDUCATION AND MEDICINE 



tion. In forward flexion, side bending, and rotation the spine is 
unlocked and all the vertebrae rotate equally and in the same di- 
rection. Extension of the spine 
locks the vertebree, both dorsal 
and lumbar, and limits rota- 
tion, especially of the lumbar 
vertebrae. The vertebras are 
not freely movable then ex- 
cept in the forward and side 
bending position, which un- 
locks the articulations and 
permits extensive rotation. It 





Fig. 334- — Lateral curvature from un- Fig. 335. — The result of raising the foot 

even extremities and deformed pelvis. The 3 inches to bring the spines of the ilium 

black spots mark the posterior superior to the same level, 
spine of the ilium. 

is least movable in hyperextension. For this reason the forward 
position or flexion is chosen for forcible correction of the de- 
formed spine. 

Torsion in the erect position is greatest in the cervical region, 
gradually disappearing through the dorsal. In the lumbar region 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 42 1 

it is diminished by extension, and is slight even in the erect 
position. 

The causes of scoHosis are both congenital and acquired. 
Among them may be mentioned wry neck, defective hearing, 
and vision, especially astigmatism (Gould), asymmetry (Figs. 
334) 335) 01" faulty development of the bones, rickets, con- 




Fig. 336.- 



-Showing tilting of head due to astigmatism and producing spinal deformity 
(Gould). 



genital dislocation of the hip, arthritis, uneven development of 
the lower extremities from joint disease or other causes, empyema, 
and infantile paralysis. These causes give rise to the most severe 
and intractable cases, and are the least amenable to exercise ex- 
cept as an accessory form of treatment. 



422 



EXERCISE IN EDUCATION AND MEDICINE 



It is to bad posture by long-continued standing, sitting, and 
lying, joined with the carrying of weights in the hands or sus- 
pended from the shoulder, that we must look for the origin of 
the vast majority of cases which 
may be classed under the general 
heading of the scoliosis of fatigue. 

A frequent fault in the stand- 
ing posture is the habitual em- 
ployment of one leg, usually the 
right one, as a base, the other 





Fig. 337. — Lowering of the right shoulder 
from resting the weight on the right leg. 
One way in which a C curve begins. 



Fig. 338. — Pose from an antique statue 
of a boy illustrating the attitude of rest 
with the weight on the right foot. The 
right hip projected and right shoulder 
lowered, forming a C curve. 



foot being used as a prop (Fig. 337). This produces a C-shaped 
curve, with marked lowering of the right shoulder and promi- 
nence of the right hip. Many children assume this position, in 
which the strain is borne by the ligaments of the hip and spine 
for long periods, and feel uncomfortable when the weight is 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 423 

transferred to the other foot. Such cases are nearly always 
accompanied by rounding of the shoulders, flattening of the 
chest, protrusion of the abdomen, and rotation of the vertebree 
— all signs of muscular fatigue and ligamentous strain. 

The sitting posture is beset with possibilities for deformity. 
The common habit of sitting with one foot tucked up on the seat 
is responsible for some cases, but, above all, the compulsory 
holding of any fixed position for long periods of time. We know 
that if we hold the arm out at right angles the pain and fatigue 
soon become intolerable, and few can stand the strain so long as 
five minutes. The greatest strain falls upon the deltoid, which has 
no relief from continuous action. The same condition occurs in 
the back and shoulders of the school child forced to remain sitting 
for any unusual length of time. The complicated system of 
spinal muscles, by working in relays, postpones fatigue very con- 
siderably, the sUghtest change of movement bringing into action 
a new set and reheving the tired ones; but the constant desire for 
rest by movement is the most striking quality of all young 
animal life. 

With the beginning of school life the child is made to sit from 
three to six hours with but momentary rests at long intervals, 
and the resultant restlessness must be suppressed by the teacher 
for the sake of discipline. The rapid fatigue of the undeveloped 
muscle and the irregular compression of the growing bones go 
far to fix the faulty posture, especially in those who are weak and 
dehcate. 

The onset of this deformity is hastened by mental fatigue, 
which is faithfully reflected in the posture, the face, and the 
general listlessness of the child. 

The influence of a bad sleeping posture in the causation 
of curvature has been well pointed out by G. W. Fitz (Fig. 
339). The hips and shoulders, being the broadest part 
of the trunk, serve as points of support and leave the middle 
portion of the body suspended between them, and, as the period 
of sleep occupies one-half to one-third of the child's growing 
time, this influence is of importance. Observations on the 



424 



EXERCISE IN EDUCATION AND MEDICINE 



attitude of 320 healthy sleeping children — 156 boys and 164 
girls — made by E. G. Brackett, showed that about 20 per 
cent, more lie on the right than on the left side, while more lie 
on the back than on either side. These figures were confirmed 
by Hare, but the greater frequency of the lying position on the 
right side is partly explained by the fact that the boys observed 
were all required to lie upon the right side when they went to 
bed to prevent conversation. Two hours later they had turned 
on the face, the back, or the left side. 




Fig. 339. — A double curvature encouraged by bed-posture, as seen in the upper picture, 

and corrected by turning over on the other side (Fitz). 



As will be seen by the illustration, a patient with left convex 
curve in the lower dorsal region should not He habitually upon the 
left side. 

Curvature may begin at either end of the spinal column, 
the most flexible parts being in the lumbar and cervical regions. 
If it begins in the cervical region from torticollis or from eye 
defects, other curves will be secondary, while if the curvature 
begins in the lumbar region from unequal support of the pelvis, 
either in sitting or standing, the dorsal curvature will again be 
secondary. An S-shaped curve can be produced experimentally 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 425 



by raising the left side of the seat to tilt the pelvis, making 
a lumbar curve with the convexity to the right and a compen- 
sating curve in the opposite direction (Figs. 340, 341). 

The frequency of scoliosis among school-children and youths 
may be gathered from the fact that in an examination of 122 
high-school boys entered for an athletic meet I found it in 32 
cases, or 19 per cent. In an examination of 446 athletic college 
students it was found in 19 per cent. In another series of 200 
college students it was well marked in over 8 per cent., and 





Fig. 340. — Straight spine with even sup- 
port of the pelvis. 



Fig. 341. — S curve caused by uneven sup- 
port of the pelvis in a normal individual. 



slight in an additional 16 per cent. In a girls' high-school, out 
of 160 examinations, it was found in 31 cases, or 19 per cent., 
accompanied by severe backache in 17 cases. The figures of 
other observers, like Gullam Krug, Hagman, Kalback, Schotter, 
Eulenberg, Roth, and Whitman, give an average of about 27 
per cent, among school-children, and place the period of greatest 
frequency between the ages of seven and fourteen. 

The most frequent form of scoliosis is the total C-shaped 
curve, involving the entire back (Fig. 342). 

In his series of 1000 consecutive cases, taken from a large 



42 6 EXERCISE IN EDUCATION AND MEDICINE 

private practice, Bernard Roth found 523 presenting this type; 
329 presented a right dorsal and left lumbar (Fig. 343), 72 of his 
cases showed a total right curvature, while 33 might be classed 
as irregular. This is substantially the same proportion as in 
Scholder's examinations of school-children at Lausanne. His 
entire table is as follows: 

Among 571 school-children with lateral curvature, out of 
2134 children examined, 60.3 per cent, showed curves convex 




Fig. 342. — C curve in a young woman. Fig. 343. — Tracing of tj'pical S-sliaped curve. 

to the left, 2 1. 1 per cent, showed a right convex curvature, and 
8.5 per cent, showed compound convex curves. His totals are: 

, Left convex. Right convex. Total. 

Per cent. Per cent. Per cent. 

Total scoliosis , . . .48.1 7.8 56.0 

Dorsal scoliosis 8.4 4.3 12.7 

Ltimbar scoliosis 11.8 8.5 20.3 

Combined scoliosis 8.5 ... 8.5 

The total curve is most commonly found in school-children, 
and is followed by the right dorsal and left lumbar. Transi- 
tional cases are nearly always preceded or accompanied by round 
shoulders, flat chest, and protruding abdomen, and by general 
carelessness in carrying the body weight when standing at rest, 
as in Fig. 337. This alone would tend to produce a well-marked 
total curve, with the convexity to the left. As this posture be- 
comes fixed the bodies of the lumbar vertebrae rotate to. the left, 
and this part of the curve tends to become more pronounced and 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 427 



localized, a compensating curve developing in the opposite direc- 
tion in the dorsal region. This process happily may be arrested 
at any stage of its course. 

Curvatures beginning at the upper end of the spinal column 
are usually caused in school-children by torticollis, deafness, or 
by uncorrected astigmatism, and by faulty positions in sitting 
and in writing, where the head is tilted to the left and twisted 
to the right, as in facing a strong wind. This causes a rotation of 
the bodies of the cervical vertebrae to the right, carrying with it 
the bodies of the dorsal vertebrae, producing the characteristic 
right dorsal curvature with rotation to the right and followed by 
a left convex lumbar, the level of the 
greatest deviation in these cases being 
usually from the sixth to the eighth 
dorsal. 

In total curvatures the deviation is 
greatest lower down, about the ninth or 
tenth dorsal, or even at the twelfth. In 
curvatures beginning from some distor- 
tion of the pelvis or irregularity in its 
support the curvature is usually situ- 
ated low down in the lumbar region 
(Fig. 344). 

Scoliosis is frequently found in more 
than one member of a family, in twins 

or sisters, in mother and daughter, or aunt and niece, so that 
such facts should be obtained at the examination, as well as the 
susceptibility to illness and fatigue, rapidity or retardation of 
growth, and time of dentition. 

Signs of rickets, like bow-legs, the ''rosary," or the charac- 
teristic shape of the head, should be well noted, and the history 
of any severe constitutional diseases, as well as the general 
habits of life, such as the length of the school hours, the amount 
and nature of exercise, and the habitual standing and sleeping 
posture. The mother should be asked how the curvature was 
noticed, for it is frequently discovered first by the dressmaker 




Fig. 344. — Tracing illus- 
trating a G curve as a result 
of uneven extremities. 



428 EXERCISE IN EDUCATION AND MEDICINE 

in some casual way, such as the sHpping of the clothing, inequality 
of the two sides of the skirt, or unevenness in the shoulders, and 
in all such cases it has probably existed for a long time unrecog- 
nized. The patient should then be stripped, the length of the 
legs measured, the presence or absence of fiat-foot should be 
observed, as well as any marks on the body from pressure or 
faulty support of the clothing. The spinous processes should then 
be marked by a flesh pencil, and the levels of the shoulders and 
inferior angles of the scapulae should be noted, while the patient 
stands in a natural position with the heels together. Slight pro- 
jection of one hip can be quickly detected by noticing the varia- 
tion in the size and shape of the space between the arm and 
side, seen from behind, as pointed out by Jakob Bolin. FlexibiKty 
should be tested by having the patient bend to either side and 
then forward, with the knees straight (the Adams position), 
which best displays any rotation, and the examiner's hands may 
pass up and down the sides of the spine to feel any irregularity. 
The habitual posture having been found, the patient should be 
placed in the best possible position, the keynote for future treat- 
ment, as Bernard Roth has so well insisted. 

Before beginning a course of treatment the extent of the 
curvature must be recorded accurately if we are to follow the 
effects of treatment. This record must show the difference in 
the height of the acromia and inferior angles of the scapulae, 
the deviation of the spinous processes from the straight line, 
the difference in outhne and level of the hips and iliac crests, 
rotation of the vertebras, both dorsal and lumbar regions, and, 
if necessary, the condition of the anterior and posterior curves. 

For this purpose photographs are much employed, usually 
with a screen, but the most vital objection to their use as a 
routine practice is their expense, both in time and money, and 
the difficulty of getting them, and their liabihty to mislead the 
observer by imperfections or changes in the lighting of the figure 
at different times. Spellissy has devised a uniform photographic 
method which would be of value if the conditions he requires 
were observed — (i) A standard focal length of lens; (2) a stand- 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 429 

ard focus and distance of subject from lens front; (3) a standard 
direction of lighting for recording purposes; (4) a standard size 
of image and of division of chart for comparative illustrations; 
and (5) a standard series of poses in faulty, habitual, and cor- 
rective posture. The use of plumb-lines is the cheapest and 
simplest, deviations from the vertical line being noted at different 
levels, and rotation can be recorded by molding a flexible strip 




Fig. 345. — Schulthess apparatus for recording lateral curvature (Liining and Schulthess). 

of tin across the back at the desired level and making a tracing 
from this upon paper after the method of Bernard Roth. A 
rapid method of recording the deviation is by attaching a strip 
of adhesive plaster to the spine and marking the position of the 
spinous processes on it. 

The most accurate and convenient instruments are those 
employing the pantograph method, of which the most elaborate 



43° 



EXERCISE IN EDUCATION AND MEDICINE 



is that of Schulthess, which gives a Hfe-size tracing of all the 
contours. Its size and expense, however, make its general 
introduction impossible (Fig. 345). 

An attempt has been made to fulfil these conditions in an 
instrument which I have employed for some years. It consists 





Fig. 346. — Making a tracing of the lateral de- 
viation by the author's scoliosiometer: a, Pointer 
which follows the line of the spinous processes and 
tips of the scapula;; b, pencil recording the trac- 
ing on paper to the scale of i to 4; c , fixed point of 
the pantograph. 



Fig. 347. — The author's scoliosi- 
ometer, showing the clamps for hips 
and shoulders and the pantograph 
in place. 



of a horizontal iron stand into which a rigid upright rod is firmly 
screwed. To this rod two jointed arms are attached by movable 
collars clamped by thumb-screws. The lower arm passes behind 
the patient and fixes the hips by means of clamps preventing 
any sideward movement. The upper arm passes in front of the 
patient and fixes the shoulders. To the collar of the upper arm 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 43 1 

a plate is hinged for the attachment of the pantograph, set to 
make the tracing in the proportion of i to 4. Ruled paper is 
stretched over the plate and held by clips behind. The pointer 
should be adjustable in length, short for the tracing of the spine 
and scapulae, and capable of being lengthened for tracing the 
outline of the shoulders and hips. 



Fig. 348. — Making a tracing of the rotation at the lumbar region. 

To take a tracing the spinous processes are first marked with 
a flesh pencil. The patient is placed on the stand with the heels 
together, the hips clamped at the level of the trochanters, and 
the shoulders clamped after the patient has settled into the 
habitual position. The line of the spine is followed by the 
short pointer, the gluteal cleft and the points of the scapulas 
are marked, then an outline of the shoulders and hips is 



432 EXERCISE IN EDUCATION AND MEDICINE 

rapidly traced by lengthening the pointer to touch the most 
prominent parts. Cross-sections may be taken to show rotation 
by passing the end of the pantograph across the back, at the 
desired level, the patient bending forward (Fig. 348) . A tracing 
of this kind gives an accurate map of the back, showing the dif- 
ference in levels, deviation, and rotation, their extent being to 
scale, and estimated by counting the squares on the ruled paper. 




Fig. 349. — Case of tubercular spondylitis simulating scoliosis, showing lateral and 
rotary deformity. The onset was very rapid and the rigidity great. The diagnosis was not 
made until treatment by exercises had increased the deformity and rigidity. The de- 
formity was gradually corrected under treatment by immobilization (Ridlon and Jones). 

These tracings should be repeated from month to month 
throughout a course of treatment. 

Diagnosis. — Scoliosis must be carefully distinguished from 
Pott's disease or tuberculosis, symptoms of which are spasm of 
the muscles and loss of mobihty in the spine, with pain on 
motion or jar, pains in the chest and abdomen, fever, and im- 




SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 433 

pairment of the general health. Lateral deviations occur in the 
course of this disease, but it is usually a leaning of the body to one 
side rather sharply instead of a true gradual curve. In later 
stages a knuckle of bone develops at the seat of the disease, but 
the danger of mistaking it lies before this has developed. 

In rickets the malformations of the various bones may 
usually be discovered by examination and measurement, and the 
other constitutional symptoms are charac- 
teristic, the curves of the spine being gen- 
erally rather sharp and often accompanied 
by great thoracic deformity. 

In infantile paralysis there is a manifest 
loss of power in the affected muscles which 
renders its diagnosis comparatively easy, es- 
pecially by the aid of electricity. In these sco^£is'd°u7to ''collapse 
cases the deformity usually becomes great of right side after empy- 
and the condition is resistant of treatment. *^.7^ ^^ resection o 

ribs. 

Curvatures resulting from pleurisy and em- 
pyema are always toward the convex healthy side of the chest (Fig. 
350), and are easily distinguished by the history and appearance. 
The symptoms, apart from the deformity, may not be very 
prominent in slight cases. The dressmaker conspires to con- 
ceal it by making one side of the skirt longer, or by changing 
on one side the distance of the armhole to the waist-band, 
but patients usually have a feeling of one-sidedness. They are 
often observed to have a distinct limp, and a very consider- 
able number, especially young women, complain of backache 
more or less severe, sometimes bilateral, sometimes on one side 
only, usually situated in either the lumbar region or about the 
point of the scapula. In severe cases there may be pressure upon 
the nerve-roots causing pain. The early onset of fatigue, with 
shortness of breath, is common on account of the diminished 
capacity of the lungs and interference with the heart action, 
but these symptoms are pecuhar to the more aggravated cases. 
As the deformity tends to increase during the growing period 
these symptoms may not become insistent until the approach 
28 



434 



EXERCISE IN EDUCATION AND MEDICINE 



of adult life, when the patient is prone to develop phthisis or 
to have disturbance of the digestion, impairment of the general 
vigor, and slow increase of asymmetry, with pains in the back, 
as senile atrophy of the intervertebral disks progresses. 

Prognosis. — Total functional curves may continue as such 
throughout life, increasing slightly, although, as a rule, they 
change to structural curves and become compound in form as 
they progress. Some permanent deformity is certain in all 
cases where a functional curve has become structural and the 
vertebras have become distorted. By exercise, rest, and some- 
times forcible correction, all but structural cases should be 
capable of permanent cure, and even they should be in every 




Fig. 351. — Course of the S curve under treatment. 

case greatly improved, the deformity masked and corrected, and 
the general health and efficiency retained.^ 

This applies more especially to children who have not yet ac- 
quired their full growth. When full growth has been attained 
before the case comes under observation complete cure is not 
always to be hoped for, and the only thing to be expected is some 
improvement in the general condition and a variable diminution 
of the deformity. Cases due to infantile paralysis, or to the 
collapse of one side of the chest from empyema, are peculiarly 
resistant and must be treated with great caution. Cases due to 
rickets are also resistant, although most of them are capable of 
considerable improvement. 

^ "Report of Committee on Scoliosis," American Journal of Orthopaedic Sur- 
gery, July, 1 9 14. 



CHAPTER XXIV 

THE TREATMENT OF SCOLIOSIS 

The treatment of scoliosis falls naturally into two divisions — 
(i) The reformation of the physical habits and improvement 
of the general condition; (2) the correction of the deformity by 
exercise, stretching, and support. 




Fig. 352. — ^The hand in the writing posture as usually ordered, but not practised, because 
to the writer the writing field is hidden by the thumb, finger, and holder (Gould), 

Correct standing posture must be taught by the aid of a 
mirror, as described in the chapter on Round Shoulders. This 
must be insisted upon in season and out of season until it can 
be maintained without fatigue. Astigmatism should be at once 

435 



436 



EXERCISE IN EDUCATION AND MEDICINE 



corrected where it is the cause of tilting of the head, and the 
habits of school Hfe should be carefully regulated to allow fre- 
quent rests. 

The writing posture favors the formation of fatigue scoHosis 
to a marked extent. Schanz does not beheve that there is any 
difference between the slanting and vertical script as a cause, but 
the usual directions given for the correct writing position place 
the hand between the eye and the writing field, which is hidden 




Fig' 353- — Change of posture of body and head, the paper shown, and the penholder 
angled in order to bring the writing field into view (Gould). 



by the thumb and finger and the penholder (Fig. 352). As a 
consequence, the pupil turns the paper to the left and the pen to 
the right, accompanying this by twisting of the head further to 
the left, with the chin tilted to the right (Fig. 353). If the paper, 
instead of being placed in front of the pupil, be placed to the right 
of the body line, these difficulties are overcome and the child ob- 
tains a clear view of the writing field, the only possible de- 
formity then being a forward bending of the head. 



THE TREATMENT OF SCOLIOSIS 



437 



The rule for the construction of a well-fitting desk is so 
simple that there seems no excuse for neglecting it. The height 
of the seat from the floor should be such that in sitting the feet 
rest easily on the floor or on a foot-rest. The slope of the seat 
should be backward and downward in the proportion of one in 
twelve, the depth being about two-thirds the length of the thighs 
and the width that of the buttocks. Making it concave adds 
to the comfort. The back of the seat should have a slope back- 
ward of about one in twelve from a vertical line, and the back 
support should come to the middle of the shoulders and touch 
the small of the back. The 
height of the desk should be 
such that the back edge allows 
fair room to rest the forearm 
naturally with the elbow at 
the side, and the slope should 
be about one to six forward 
and upward, the edge over- 
lapping the front edge of the 
seat by about i inch. The 
desk may well be made ad- 
justable for distance (Fig. 354, 
a,b),&o as to allow freedom in 

getting in and out by pushing the desk-lid forward. These 
points are covered in the Garber adjustable desk, described in tHe 
chapter on Schools. 

Poor lighting of the schoolroom is a third source from which 
scoliosis begins. If the pupil cannot see clearly he bends for- 
ward or twists his back, and the same effect is produced if he 
sits in his own light. A well-designed schoolroom should have 
windows placed high enough to let the light fall over the left 
shoulder, and never directly from in front or behind. 

The raising of one side of the seat will reverse a beginning 
curvature (Figs. 340, 341), and this may be used as an auxiliary 
means of treatment by placing the patient upon such a seat 
from one-half to one hour daily. Where one leg is short the foot 




Fig. 354. — To show the measurements 
required in determining desk proportions, 
a-b is the distance which is here minus, 
because the edge of the desk overlaps the 
front of the seat. 



438 



EXERCISE IN EDUCATION AND MEDICINE 



should be raised by wearing an insole of cork in the boot, and a 
child who habitually rests with the weight on the right leg (Fig. 
337) should be trained to reverse the resting posture by using 
his left leg as the habitual base of support. 

The main corrective treatment of scoKosis must, however, be 
by active exercise and stretching, and the muscles must be 
developed and trained to 
maintain the correct pos- 
ture with ease. Treatment 
must be thorough and reg- 
ular, extending from one- 
half to one hour daily, and, 
even after an apparent cure 





Fig. 355. — ^A girl aged seven years 
with severe osseous lateral curva- 
ture of the spine, in the "habitual" 
posture (Bernard Roth). 



Fig. 356. — Girl aged seven years, with severe os- 
seous lateral curvature of the spine, when placed 
in the "keynote" posture (Bernard Roth). 



has been obtained, the patient should be kept under close obser- 
vation for at least two years to check the first signs of relapse. 

Every course should begin with what is known as "straight 
work," such as is described for round shoulders, in which the 
muscles on both sides are equally employed, with special em- 
phasis laid upon chest development, but in a few days one- 



THE TREATMENT OF SCOLIOSIS 



439 



sided movements should be introduced in appropriate cases, such 
as are described for the raising of the right shoulder, and gradu- 
ally stretching movements should be taught, like those pictured 
in Figs. 365 and 412, the right or left foot only being used and 
the surgeon grasping the left or right hand, producing a diagonal 
tension on the spine. All free movements should be done in the 
keynote position, which is found experimentally by holding the 
arms so as to give the greatest correction of the curvature. 
This may be with the right arm up and the left arm out, or 
with the right arm up and the left arm down, or with both arms 
above the head, or the right arm out and the left up (Figs. 355, 
356). It must be found after repeated trials for each individual 
case. 





Fig. 357. — Direction of the pull of the psoas on the lumbar spine. 

As most children suffering from scoliosis are below the 
normal in strength and resistance, it is essential that exercise 
should not be pushed beyond the point of general fatigue, and the 
greatest care should be taken to limit the number of muscle 
groups exercised to those more directly affected, so that the 
resulting fatigue may be localized to them and not spread over 
the whole muscular system. Much of the discredit under which 
the exercise treatment of scoliosis labors has been due to the in- 
accuracy of the exercises. 

In applying asymmetric exercises it is to be remembered 
that the most freely movable regions of the spine — the cervical 
and lumbar — are the most abundantly provided with muscles, 
some of which can be isolated in action. In the lumbar region 



440 EXERCISE IN EDUCATION AND MEDICINE 

the femur can be used as a lever to pull on the bodies of the verte- 
bra^ by means of the psoas (Fig. 357). As rotation of the lumbar 
spine takes place about the articular facets acting as a pivot and 
behind the origm of the psoas, the right psoas could thus be 
made to pull the bodies of the lumbar vertebra? over to the right, 
and would help to unwind a rotation to the left. The problem is 
to put into action the right psoas muscle without involving too 
many additional muscle groups. If we flex one or both thighs,, the 
abdominal muscles do most of the work. If, however, the right 
thigh only be flexed and the left heel pressed backward against 
the table, the patient being recumbent, the abdominal muscles 
may be relaxed, and a comparative isolation of the right psoas 
obtained with a httle practice (Fig. 358). 




Fig. 35S. — Raising right foot with weight attached to exercise right psoas muscle. 

The intrinsic muscles of the back, known collectively as the 
erector spina?, are most complicated in their distribution, their 
very complexity being useful because its strands may be employed 
in relays, the tired fibers being replaced by fresh parts and the 
onset of fatigue accordingly postponed. It is very thick and 
fleshy in the lumbar region, where its two main divisions are 
defined, the outer tendons going to the six lower ribs just out- 
side their angles and prolonged upward to the head in relays, 
and the inner division, more thick and fleshy, going to rib and 
transverse process throughout the entire dorsal region, with 
an additional bundle going from the second lumbar spine to the 
first dorsal (Fig. 331). The deeper layers of this inner division 



THE TREATMENT OF SCOLIOSIS 



441 



fill the hollow between the transverse and spinous processes, the 
general direction being forward and inward, while in the lumbar 
region muscular slips go between adjacent transverse processes 
as well as between the spines. The general action of this mus- 
cular mass is to act Uke a bowstring on the spine, and to pull 
down the ribs on the active side, at the same time increasing 
lordosis. The quadratus lumborum is a depressor of the last 
rib and acts with the erector spinae of the same side. 

The lumbar and lower dorsal portions of the erector spina; 
are isolated in action alternately in the act of walking, as can 





Fig. 359. — a, Erector spinae in action during forward bending; b, left erector spina in 
action during support on right leg in standing or walking. 



be demonstrated readily by placing the hands over the loins and 
feeling them spring into action at each step (Fig. 359, b). Support 
of the weight on the right leg involves a contraction of the left 
lumbar erector spinae. Support of the weight on the right arm 
and the feet, as in the diagram (Fig. 360), brings into action the 
right erector spinae, but if the support be at the hips the action 
is reversed, except in the cervical region (Fig. 361). In the dorsal 
region the muscles are much thinner, more tendinous, and parts 
degenerate into ligamentous bands, the dorsal spine being much 
less directly moved by muscular action than either the lumbar or 
cervical. The ribs can be employed as levers on the dorsal region, 



442 



EXERCISE IN EDUCATION AND MEDICINE 



and the thoracic cage, with its muscular attachments, can thus 
be made an active means for correcting deviation and rotation. 




Fig. 360.- 



-Action of right erector spinae in dorsal crossing to left side during support at 
feet and shoulders. 



In movements where the humerus is fixed and the spino- 
scapular muscles contracted, the spinous processes are pulled 
over to the active side by the trapezius, the latissimus dorsi. 




Fig. 361. — Left erector spinae in action during support at hip. 

and the rhomboids. If the pectorals of the opposite side be 
contracted, an additional torsion is exerted on the dorsal spine. 
The dorsal region can also be reached through the action of the 




Fig. 362. — ^Torsion of thorax by muscular action. 

respiratory muscles. The upper ribs being first fixed in forced 
inspiration by the scaleni, serratus posticus superior, and the 
sternomastoid, the thorax is flexed toward the convex side, the 



THE TREATMENT OF SCOLIOSIS 443 

walls of the collapsed side forced out, and the rotation of the 
ribs and deviation of the spine lessened by this movement. 

In the cervical region the erect spine is extended by the 
splenius capitis and colli, by the complexus, and by the reap- 
pearance of muscles ligamentous in the dorsal region, in addition 
to the obliques and recti of the suboccipital triangle, all forming 
the thick, fleshy mass of the back of the neck. Movement here 
is very free in all directions, notably rotation or torsion, which 
takes place largely at the first two cervical joints through 
the action of the inferior obliques and the more superficial 
muscles, which are all directly accessible to exercise. 

A muscle can be developed only by active contraction and re- 
laxation. Continuous tension quickly tires and lowers its tone, 
as has been already stated, so that in prescribing exercise it is 
necessary to distinguish between those given for the purpose 
of increasing muscular tissue and power, which should be com- 
paratively quick and frequently repeated, and those which aim 
at the stretching of muscles and ligaments, which should be slow 
and long maintained. 

In describing the gymnastic treatment of scoliosis the curves 
will be considered in the order of their frequency, and, without 
attempting to give an exhaustive list of all possible exercises, 
those that are described will be arranged in the form of pre- 
scriptions for typical cases and illustrated by case reports. 

All exercises and stretching movements should be given daily, 
with a period of rest after three or four movements. They should 
be so alternated and combined that no two employing the same 
muscles in the same way should follow one another and so cause 
excessive fatigue. 

The most frequent deformity is a total left scoliosis or 
C-shaped curve, and the following prescription of exercise would 
be indicated: 

Exercise I. — Position, standing, hands at the side. Right 
arm forward and upward raise, inhale, upward stretch, rise on 
tiptoes, and raise left foot sideward, upward stretch, arm and 
foot sideward lower to the standing position (Fig; 363). 



444 



EXERCISE IN EDUCATION AND MEDICINE 



This movement will develop the upper part of the trapezius, 
rhomboids, and deltoid of the right side, raising the shoulder and 
stretching the thorax. At the same time, the uneven support 
brings into strong action the lower part of the left erector spinas. 
Exercise II. — Position, standing, fingers interlocked behind 
the back. Roll the shoulders backward, supinating the arms 
(Figs. 307, 308), and then bend body to the left. 

This exercises stretches all . the 
anterior muscles and ligaments of 
the shoulder-girdle, improves its 
flexibility, and reverses the curve. 





Fig. 363- Fig. 364. 

Exercise III. — Position, standing, left foot forward, lunge, 
hips firm. The right arm sideward, raise, inhale, upward stretch, 
forward bend until the right hand touches the floor in front of the 
left foot; upward stretch, exhale. This may be varied by bending 
from the standing position with left arm extended backward 
(Fig. 364). 

This movement, besides developing the upper right shoulder 
muscles, improves the lung power by filling the lungs in their 



THE TREATMENT OF SCOLIOSIS 445 

most favorable position and compressing the air in the down- 
ward bending movement. The right side of the thorax is stretched 
during the forward bending movement, and the left latissimus 
dorsi is contracted by pressing downward on the left hip with 
the left hand. 

Exercise IV. — Patient supine on the plinth (sit lying), with 
the right knee over the end, the left arm behind the back, and 
the right hand grasped by the surgeon. Starting with the elbow 
at the side, the surgeon pulls the arm up slowly sideward and 
upward, the patient resisting. When fully extended above the 
head the surgeon exerts as much tension as possible, counting 




Fig. 365. — Stretching of right side. 

five. The patient then draws the arm down to the starting 
position, the surgeon resisting (Fig. 365). 

In this stretching movement the two points at which the 
stretching power is applied are the right hip and the right 
shoulder, so that this tension will reverse the curve and stretch 
the right side of the trunk. 

Each of these exercises should be repeated at least twenty 
times, and should be followed by a short rest, after which the 
following should be given: 

Exercise V. — Patient's right leg lying, strapped to the plinth, 
the right neck and the left hip firm. Side flexion of the trunk 
(Fig. 366). 



446 



EXERCISE IN EDUCATION AND MEDICINE 



In this exercise it will be necessary for the surgeon to assist 
most patients at first, and to urge them to bring the body as 
high as possible. The entire erector spinae mass on the left side 




Fig. 366. 

is powerfully employed, and the effect may be still further in- 
creased by placing both hands behind the head. 




Fig. 367. 

Exercise VI. — Patient prone (forward lying) with both feet 
strapped to the plinth, right arm extended upward. Move- 
ment: Trunk extension, forcing the right arm forward and the 
left arm backward (Fig. 367). 



THE TREATMENT OF SCOLIOSIS 



447 



Exercise VII. — Patient supine. Raise the right arm forward, 
upward stretch, inhahng slowly, sideward lower, exhahng. 

This should be repeated at the rate of twelve to the minute, 
and the maximum amount of chest expansion secured at each 
repetition. 

Exercise VIII. — Patient prone, the left foot only fast- 
ened. Trunk extension with the movement of swimming, as 
in Figs. 313-315. This should begin by repeating the swimming 




Fig. 368. — Self-suspension with pressure on the left side to correct rotation. 

movement five times, followed by a rest. Gradually patients 
will be able to go up to twenty or thirty times without resting. 
These exercises should be followed by a rest. 

Exercise IX. — Suspension with lateral traction. The pa- 
tient puts the head in a Sayre sling and grasps the cord pre- 
paratory to self -suspension. A band of webbing is placed about 
the point of the greatest deviation on the left side, usually about 
the tenth dorsal (Fig. 368). Movement — the patient pulling 



448 



EXERCISE IN EDUCATION AND MEDICINE 



on the cord raises himself from the ground, while the surgeon, 
by means of a cord and pulley, draws him sideways, stretching 

the right side. Repeat ten times. This 
should be followed by a rest. (See 

Fig. 319-) 

Exercise X. — Position, right neck 
firm, left hip firm; movement, side 
bending to the left. 

The treatment should end by deep 
firm stroking from above downward, 
about ten or twelve times on each side, 
using one hand to press upon the other. 
The following is a typical case re- 
port: 

V. O., aged twenty-one, consulted 
me April 20th. At the age of eight 
years she fell down- stairs and was con- 
fined to bed for three months. She 
states that since then she has been 
suffering from pains in the back at the 
point of the right scapula, burning or 
boring in character, much worse after 
sitting still for any length of time. 
Has been unable to attend school or do any work on account 
of pain and fatigue. 

Examination. — 111 nourished and anemic, flat chest, promi- 
nent abdomen, projecting chin, and round shoulders. Right 
scapula i^ inches lower than the left (Fig. 370). Total left 
scoliosis, with deviation greatest about the ninth dorsal. Rota- 
tion slight, flexibihty good, the ihac crests even in height. 
Patient winces on pressure over the point of the left scapula 
and left lumbar region. 

Treatment. — Prescription of exercises, such as described, with 
one hour rest daily, recumbent, in the afternoon. 

May 28th. — She has been at work daily for one month. 
Right shoulder still lower, but the improvement very marked, 




Fig. 36g. 



THE TREATMENT OF SCOLIOSIS 



449 



and the spine almost straight (Fig. 370). Occasional pains, not 
constant in location or duration, probably hysteric in character. 






I 



Fig. 370. — Tracings taken at the beginning and after one month's treatment by rest and 

exercise only. 

General condition much improved. To continue daily work at 
home for one month. 





Fig. 371- 



Fig. 372. 



June 30th. — Improvement retained. Can attend to social 
duties without any discomfort. The salutary effect of the 



450 



EXERCISE IN EDUCATION AND MEDICINE 



exercises on the general condition of this young woman was 
most marked. 

In a right dorsal and left lumbar curvature (Fig. 343) the 
following prescription would be applicable: 

Exercise I. — Position, standing, hips firm; movement, left 
arm and left leg sideward raise, inhale, and upward stretch, 
sideward lower, exhale (Fig. 371). 

In this the left side of the thorax, which is contracted by. the 
rotation of the ribs on the right, will be stretched, and the left 




Fig- 373- 



lumbar curve will be reversed by the tilting of the pelvis and the 
contraction of the left erector spina.^ mass in the lumbar region. 

Exercise II. — Patient standing, with lingers interlocked. 
Rolling of the shoulders into supination, with forward bending 
and twisting to the right (Fig. 372). 

Exercise III. — Position, standing, hands at the sides. For- 
ward lunge with the left foot, the right hand on the hip. Left 
arm sideward raise, inhale, forward bend, touching floor; rise 
and exhale, returning to standing position (Fig. 373). 



THE TREATMENT OF SCOLIOSIS 45 1 

The lunge tilts the pelvis down to the right, reversing the 
lumbar curve, and the raised left shoulder reverses the dorsal 
curve. 

Exercise IV. — Position, supine on the plinth. Raise the 
right foot 1 2 inches from the pKnth, pressing back with the left 
heel, hips firm. 

The tension on the right foot should be increased by placing 
shot-bags across the ankle, starting with a weight of 5 pounds 
and increasing it to 10 or 15 as the strength allows (Fig. 358). 
The patient should be carefully instructed to relax the abdominal 
muscles so that the strain may fall upon the right psoas, which 
will pull the bodies of the lumbar vertebrae over to the right and 
so unwind a lumbar rotation to the left. 




Fig. 374. 

Exercise V. — Position, prone, the right foot fixed, the left 
arm up and the right arm down. Movement: Trunk extension, 
with the stretching of the right arm backward and left arm for- 
ward (Fig. 374). 

Exercise VI. — Position, supine (sit lying), right knee over 
the end (Fig. 365), right arm behind the back, left arm grasped 
by the surgeon. Movement: The left arm is pulled upward and 
strong tension is exerted by the surgeon. The patient pulls 
the arm forward and downward, the surgeon resisting. In this 
way the rotation is unwound by the diagonal tension running 
from the right hip to the left shoulder, reversing the curves. 



452 



EXERCISE IN EDUCATION AND MEDICINE 



Exercise VII. — Position, left leg lying (Fig. 376), but with 
right hip firm, left neck firm. Movement: Side flexion to the 
right. 



J 



^ 



J 






^K 



Afvi b I 



Fig. 375. — Four tracings illustrating the progress of an S curve under treatment for three 

years. 

This exercise is aimed at the lumbar curve, which will be 
reversed by the side bending to the left in the extended position 
of the spine, essentially a motion of the lumbar region, the bodies 
of the vertebrge turning toward the concavity of the curve. 




Fig. 376. — Movement for left dorsal and right lumbar curve. 

Exercise VIII. — Position, supine. Raise the left arm and 
the right leg, inhale, lower, slowly exhale. This should be fol- 
lowed by a rest. 

Exercise I X. — Suspension by the Sayre sling or spinal assistant 
(Fig. 319). Movement: Side traction, pressure being placed on 
the left lumbar region. Repeat from ten to twenty times. 



THE TREATMENT OE SCOLIOSIS 



453 



Exercise X. — Position, left neck firm, right hip firm; side 
flexion to the right. 

This should be followed by kneading and stroking, as pre- 
viously described. 

In a left dorsal and right lumbar curve (Fig. 377) practically 
the same exercises may be used, except that in every case the 
opposite leg and arm are employed. 

Case Report. — C. C, aged thirteen, consulted me January 
27th. Examination showed the right scapula low, left dorsal 
and lumbar curves with rotation, round shoulders, flat chest, 
protruding abdomen and chin, and general relaxation of the 





\ 



^ 



V 



\ 



J \ V 



J V 



ion lid* 



RL 



Fig. 377. — Course of triple curve under treatment: Left lumbar, right dorsal, and left 

cervical. 

ligaments. General health had not been very good. Two sisters 
had already been treated for spinal curvature. 

The indications here were to develop the erector spin^ and 
extensors of the neck, to expand the chest and develop the ab- 
dominal muscles, and raise the right shoulder, reversing the 
curves. The best possible position was one in which the right 
arm was raised and the left stretched horizontally out at the 
side. 

After daily treatment lasting over two months the second 
tracing was obtained, the lumbar curvature being practically 
corrected, although there was still a dorsal curvature with the 
right scapula low. She reported twice a week for two months, 



454 EXERCISE IN EDUCATION AND MEDICINE 

taking a modified daily prescription at home. She then left the 
city for the summer, and the following October a third tracing 
was taken, showing that the improvement was retained. During 
that winter she reported once a week, and continued her exercise 
at home. Three years later a fourth tracing was taken, showing 
that the correct position had been maintained. It will be noticed 
that the patient has developed from a child of thirteen to a 
young woman of sixteen (Fig. 377). 

Curves due to infantile paralysis will require long-continued 
treatment, especially where they are severe and structural, 
localized, and fixed. In some of these cases the best that can be 
hoped for from gymnastics is to develop the general muscular 
system and to form compensating curves above and below the 



W ( ) ) I 

Fig. 378. 

primary curve, thus giving a general appearance of symmetry 
to the outline of the back. 

S. M., aged nine years, consulted me in September. Six 
years ago he had left hemiplegia, lasting six months, which, to 
all appearances, gradually passed away. About two years ago 
he noticed while walking that the left shoulder protruded (Fig. 
378, i). Examination showed a left lateral curvature high in the 
dorsal region, marked rotation, some pain over the convexity, 
and diminished flexibihty. A slight compensating curve in the 
lumbar region was present. 

After two months of daily exercise and stretching a second 
tracing was taken, showing the development of the compensating 
curve and the lowering and partial replacing of the left scapula. 
The improvement continued from September until March, when 



THE TREATMENT OF SCOLIOSIS 



455 



a third tracing was taken, showing a lowering of the scapula at the 
expense of an increase in the lumbar curve (Fig. 378, 2). This 
was the extent of the improvement obtained, but the general 
appearance of the back, especially when dressed, was very much 
better and the muscular development and general efficiency 
greatly improved. 

Where the curvature is due to inequaUty of the extremities, 
it must be corrected by raising the heel of the shortened side, 
which is sometimes all that is necessary (Figs. 334, 335, and 

344)- 

One of the most important points in the treatment of aU 
these cases is the development of the thorax, and it is remarkable 
how much improvement can be obtained in this direction by 
respiratory and stretching exercises. 




)"V ' 



Fig. 379. — Tracings at the beginning and after three months of daily treatment for chest 
expansion and curvature. 



One case, S. R., aged eighteen, came with persistent wearii^g 
pain in the back, round shoulders, and lateral curvature. There 
was a strong family history of tuberculosis. 

On October 7th her lung capacity, tested by the spirometer, 
showed 80 cubic inches. On November 28, after a httle over 
one month of steady work, it was no, and on January 3, 125 
cubic inches. The pains in the back had disappeared, the curva- 
ture was corrected, and her general health excellent (Fig. 379). 

Here was an increase in lung capacity of 45 cubic inches in 
three months. 

While such a result is unusual, still, after going over 30 con- 
secutive cases, I find an average gain of 21 cubic inches, and 



456 



EXERCISE IN EDUCATION AND MEDICINE 



among these were several that have increased from 30 to 35 cubic 
inches in less than three months by daily work. 




Fig. 380. — Stretching board with loops^ ready for application to a left dorsal curve (Lovett). 

In structural cases, where the treatment by gymnastics and 
posture is insufficient, stretching and retaining apparatus are 
necessary. Among the simplest is the following (Figs. 380, 381) : 




Fig. 381 . — Stretching board with loops, applied to a patient with right dorsal curve (Lovett). 

The patient lies face downward, with the knees flexed, on a 
board 3 feet wide and 4 feet long. Assuming the case to be a 
right dorsal curve, a broad canvas strap is passed around the left 
upper thorax, over and under the patient, and fastened to a cleat 



THE TREATMENT OF SCOLIOSIS 



457 



on the right side of the board. This furnishes a point of resistance 
against the left side of the upper thorax at the level of the axilla. 
A broad canvas strap is then passed around the left side of the 
pelvis, above and below, and is fastened to a cleat on the right 
side of the board. This furnishes a point of pressure against the 
left side at the level of the pelvis. A broad canvas strap is then 
placed around the thorax, on the right side, at the level of the 
greatest point of the curve. Its upper end is fastened to a cleat 
at the left side of the board; its lower end, passing beneath the 
thorax, is fastened by a string into a pulley attached to a cleat at 
the left side of the board. By means of this pulley any reason- 




J 



V 



J ^ 



Fig. 382 



-Course of triple curve under treatment by exercise and stretching only. 






able degree of force may be exerted against the right side of the 
thorax, pulling it to the left and at the same time reducing the 
rotation, because its upper end is fastened, its lower end moving 
toward the pulley. The efficiency of this apparatus is greater 
than the same movement done during suspension, because 
stretching is done more easily when^ the spinal muscles are 
relaxed. Patients should be stretched up to the point of mild 
discomfort daily, and kept in the corrected position for fifteen or 
twenty minutes. 

The application of apparatus in severe cases for retaining the 
improvement obtained by gymnastics and for overcorrection of a 
resistant curve has been carried to a high point of efificiency by 



458 



EXERCISE IN EDUCATION AND MEDICINE 



E. A. Abbott, who flexes the spine and bends it to the side, thus 
making intervertebral movement as free as possible. In this 
position he unwinds rotation by means of straps and bandages 
attached to a frame and puts on a plaster jacket in which win- 
dows are cut. Over the convexity felt pads are placed under the 
jacket, and over the concavity a window is cut to allow the ribs 
to expand under respiration. By inserting pads from time to 
time a severe deformity may frequently be completely corrected, 
and even overcorrected, the bones gradually changing their 
shape as the concave side fills the opening left for it in the jacket. 
The direction of the pull in untwisting the rotation is a mat- 
ter of dispute. Abbott's method is as in Fig. 383. . Mackenzie 





Fig- 383- — Direction of forces applied by Fig. 384. — Direction offerees applied by 
E. G. Abbott. A. Mackenzie Forbes. 

(Z. B. Adams, in Amer. Jour, of Orthopedic Surgery.) 

Forbes, in what he terms his rotation treatment, also flexes the 
spine, fixes the pelvis, and rotates the spine toward the convexity 
of the curve, thus endeavoring to reverse the curve (Fig. 384). In 
both cases the fixation in the overcorrected position must be 
followed by a long course of gymnastic exercises, to develop 
again the muscles weakened by the splinting of the spine in the 
jacket, and so preserve the improvement obtained by force. 
Improvement or cure should not be considered permanent until 
the correct position is maintained without apparatus from 
month to month, as shown by repeated records. 



CHAPTER XXV 

THE TREATMENT OF ABDOMINAL WEAKNESS 
AND HERNIA BY EXERCISE 

The upright position is not preserved by the muscles of the 
back alone. The muscular girdle of the abdomen by its tonic 
contraction is also required to keep the thorax and the abdomen 
in their proper relative positions. 

When this girdle becomes relaxed through underdevelop- 
ment or disuse it yields to the constant pressure of the movable 
internal organs, and this force of gravity, taking the lines of least 
resistance, enlarges the rings or openings through which normally 
pass the vessels and spermatic cord or round ligament. It may 
even stretch the muscle- sheaths, spread apart the weakened 
muscles, and thus allow hernia or protrusion of the abdominal 
contents. 

The four pairs of abdominal muscles have a common apon- 
eurosis in the linea alba, which is fused with the sheath of the 
rectus. The aponeurosis is pulled flat by their action, but if 
weakened and stretched the obhques lose their firm point of 
action and the abdomen bulges forward. 

During pregnancy in women of poor muscular tone and de- 
velopment it is not infrequent to have the two recti abdominis 
thus spread apart. 

In giving exercise for this condition, care would be taken to 
isolate the action of the recti and to limit as much as possible the 
side-pull of the obliques, which would only increase the trouble. 
The following exercise is used for this purpose: 

Patient supine, preferably with head lowered. Movement: 
Raise the head and shoulders (Plate I, Figs, i, 2, 3), exhaling 
during contraction, and taking care not to hold the breath at 
any time. Relax. Slowly increase the excursion of this move- 

459 



460 



EXERCISE IN EDUCATION AND MEDICINE 



ment until the body is slowly raised to the sitting position and 
slowly lowered. Repeat up to twenty times. 

This exercise should be repeated three or four times a day and 
pushed up to the point of moderate fatigue. 

Frederick W. Harvey reports several cases in which this form 
of hernia or diastasis was reduced in two months by this means 
with no recurrence.^ 

When hernia takes place at the umbilicus there is a stretching 
of the fibrous tissue alone. When it takes place at the femoral 
ring it is merely a dilatation of the innermost compartment of the 



Lower pattof 



Fascia transversalis 

Spermatic cord 

Poupart's ligament 




Lower part of internal 
oblique thrown for- 
ward 



Fie 



385. — Deep layer, showing internal ring and transversalis muscle, 
shows the attachment of internal oblique. 



The dotted line 



femoral sheath ; but inguinal hernia^ which is very much the most 
common form, is permitted only by a stretching and spreading 
apart of muscle and tendon, and exercise may be of marked 
assistance in strengthening and closing the internal and external 
abdominal rings, to guard against its advent or prevent its 
return. 

A careful diagnosis is essential to exclude femoral hernia, 
congenital arrest of development, and certain cases in which the 
bowel does not enter the internal ring, but breaks through the 
conjoined tendon directly beneath the external ring. 

The internal abdominal ring is found just beneath the cres- 

^P. E. Rev., June, 1912. 



TREATMENT OF ABDOMINAL WEAKNESS AND HERNIA 46 1 

centic arch of the inferior border of the transversalis muscle. 
It is at this point that the vas deferens in the male and the round 
ligament in the female enters the abdominal wall. The trans- 
versahs takes its origin from the outer third of Poupart's liga- 
ment. The internal oblique has its origin from the outer half, 
so that its lower fibers cover the internal abdominal ring like a 
lid, and the development of this muscle has a distinct influence 
on the ring's integrity. The external abdominal ring is a slit 
between the tendinous pillars of the external obHque, and every 
contraction of this muscle pulls these pillars together, closing it 
like a buttonhole. This action of the muscle serves as an 
automatic protector of the opening during active exercise. 



Fascia transversalis 

Spermatic cord 

Poupart's ligament 




Fig. 386. — Attachment of internal oblique, showing the covering of the cord. 



The inguinal canal, which is normally collapsed, is bounded' 
then superficially from within outward — first by the external and 
internal oblique, second by the external oblique alone. Hernia 
may enter the canal at the internal ring or break in through the 
fascia that guards its center or inner end, tearing ahead of it or 
pushing aside the weakened conjoined tendon of the trans- 
versalis and internal oblique, but in all cases it makes its exit 
by spreading apart the columns of the external abdominal ring. 

About 95 per cent, of all hernias are inguinal, and of these 
about 95 per cent, are indirect, although in infancy the inguinal 
canal is practically non-existent, the inner and outer rings 
being almost opposite. As the iha grow and extend outward and 



462 



EXERCISE IN EDUCATION AND MEDICINE 



upward the internal ring follows them, and in adult life the 
canal may be i^ inches in length. In any lateral flexion of the 
trunk, where the oblique muscles are in action, the whole region 
is flattened, and the pillars of the external ring snap together 
with the first beginning of contraction in the external oblique. 
Flexion of the trunk is done mainly by the recti, and, especially 
at the beginning of the movement, the obliques remain relaxed 
and the lower inguinal regions tend to bulge symmetrically and 
evenly (Plate I, Figs, i, 2, 3). This general yielding of the region 
just above the Poupart ligament gives color to the belief that in 
hernia acquired in adult life or in late childhood there is nothing 



Poupart's ligament 
Gimbernat's ligament 




Intercolumnar fibers 



External abdominal 

ring 
Outer or lower pillar of 

external abdominal 

ring 
Fascia triangularis 



Fig. 387. — Superficial layer and external abdominal ring. 

but the most casual connection with the spermatic cord. Some 
dissections have shown the breach to occur i inch outside the 
internal ring, and every clinician has experienced the difficulty 
of determining the exact point of entrance of the hernial sac, 
especially after the involved structures have been stretched and 
displaced. 

In the movements of straight flexion of the trunk the rectus 
muscle only is employed at the beginning and the relaxed oblique 
muscles are distended, forming two distinct pouches or weakened 
areas over the lower abdomen (Plate I, Fig. 2), and by the time 
they contract in self-protection the mischief may have been done. 



PLATE I 




Fig. I. — Patient lying with abdominal muscles relaxed. 




Fig. 2. — The beginning of flexion of the trunk, showing the recti in powerful contrac- 
tion with the obliques relaxed, allowing the lateral parts of the lower abdominal zone to 
bulge forward and distend the rings. 




Fig. 3. — The continuation of flexion showing the obliques in contraction at this later stage 

of the movement. 



TREATMENT OP ABDOMINAL WEAKNESS AND HERNIA 463 

It is in such conditions and under such circumstances that 
hernia is likely to be acquired, because hernia, like other swellings, 
enlarges in the line of least resistance. Perhaps one of the most 
potent causes is a standing posture in which the abdomen is pro- 
truded and the chest sunken, forcing down the abdominal contents 
on the relaxed lower zone, and I have been struck with the number 
of cases in which hernia came on unconsciously, without apparent 
cause, other than perhaps a long walk or a fatiguing day's stand- 
ing. Even repeated and violent effort seems less fruitful of cases 
than the dull and steady pressure on the relaxed abdominal 
walls. 

Muscular atony may of course follow severe illnesses, espe- 
cially where there is a great loss of fat, but there is also the atony 
that accompanies sedentary habits and begins to tell on those 
approaching middle Hfe, especially choosing the unused ab- 
dominal muscles as the place where the deposit of fat will be 
undisturbed, smothering their powers of contraction, resistance, 
and control. 

Symptoms. — In a great number of cases there seems to be 
plenty of warning in the shape of vague pains in the region; it is 
a frequent experience to be consulted for these pains and to find 
the ring patulous, but showing no definite hernial protrusion. 
This condition is closely associated with ptosis of other ab- 
dominal organs, and with other signs of general ligamentous and 
muscular relaxation. This dull and aching pain, either in one or 
both inguinal regions, is most common in patients who, on exam- 
ination, show unusually dilated external rings. There is tender- 
ness and a distinct impulse on coughing, but no actual hernia. 
Others, again, in whom actual hernia is present, complain of no 
inconvenience from it. 

One man played football for years with an enormous scrotal 
hernia which he did not even support. He then went to Cuba, 
did a great deal of horseback riding and other violent exercise, 
during which it disappeared. He is now quite sound, with no 
return during the past nine years and no necessity for wearing 
a truss. This is, however, far from being a typical case, for 



464 EXERCISE IN EDUCATION AND MEDICINE 

strangulation may occur at any time and forms a constant 
menace. 

Altogether, the impression I have gathered from several hun- 
dred cases coming under my own observation is that the onset, 
except in rare cases, is much less dramatic than has generally 
been thought. 

The most suitable cases for this treatment are among chil- 
dren and adolescents, where the condition is not congenital and 
where natural growth assists in the process of repair, although 
good results have been obtained up to fifty years of age, either 
where hernia is actually present or where there seem to be the 
premonitory symptoms. The great majority of cases tend to 
improve if the hernia can be reduced and kept in place long 
enough to give the rings time to recover from the stretching 
to which they have been subjected, and if in addition to this the 
obHque muscles be symmetrically strengthened by accurately 
applied exercise. 




-Seaver's flat truss pad. 

All hernias should of course be reduced, and retained, prefer- 
ably, by a truss that does not present a convexity of surface 
great enough to enter and spread the abdominal ring. The fiat 
hollow rubber pad, two inches in diameter, recommended by Jay 
W. Seaver (Fig. 388), is comfortable to the patient, can be kept 
clean at all times, and can be worn in the water without dam- 
age. It is especially suitable for young men. 

In a recent hernia, where pain is present, the patient should 
remain quiet for a week or two to get accustomed to the feel of 
the truss, and should then begin a course of light work for the 
abdominal muscles, as well as more general exercise for the whole 
muscular system. These exercises should be done daily, and 
should be increased in number, complexity, and resistance. 
The object of the exercise treatment for acquired inguinal hernia 
is twofold: 



TREATMENT OF ABDOMINAL WEAKNESS AND HERNIA 465 

(i) To strengthen and increase the number of muscle-fibers 
in the transversahs and two obhque abdominal muscles, 
and so to reinforce the aponeuroses with which they are 
connected. 

(2) To cultivate alertness, control, and self-consciousness 
in these muscles, thus causing them to respond instantly and 
automatically to any sudden strain that may be thrown upon 
them. More harm may come from surprising a strong muscle 
which is relaxed and out of control than can come from the same 
strain on a weaker muscle that is ready for it, nor must one lose 
sight of the general effect of these exercises in stimulating the 
intestines and regulating the action of the bowels. 

Great stress should be laid on teaching control of the ab- 
dominal muscles by forced breathing and abdominal exercises. 
The extent to which speciaHzation and rhythmic contraction of 
these muscles can be carried is shown in the movements of the 
Oriental danse du Ventre. As the strength and control of the 
abdominal muscles increase the work is intensified and ex- 
tended. Seaver allows his patients the most trying gymnastic 
feats, such as the lay-out on the horizontal bar. The movements 
must be varied and asymmetric. Such a movement as lying on 
the back and raising both legs to a perpendicular position does 
not produce the desired result, as the strain falls chiefly on the 
rectus abdominis and psoas muscles. The most effective move- 
ments are those in which flexion of the trunk is accompanied by 
side twisting. Great stress should also be laid on the deepening 
and raising of the chest, thus drawing up the abdominal contents 
and relieving the downward thrust of the thorax and upper ab- 
dominal structures. 

The chief precaution to be observed is to teach the patient 
how to support the dilated ring with the finger during exercise 
(Plate II, Fig. i), but if it seems inadvisable to trust to his intel- 
ligence a truss should be worn throughout the treatment. 

The following exercises have proved to be of value in over- 
coming the premonitory symptoms already described, and in 
curing the actual hernia even in severe cases: 
30 



466 



EXERCISE IN EDUCATION AND MEDICINE 



Exercise I. — Patient lying on back. Place one hand across 
abdomen, the other protecting the ring. Inhale deeply. Exhale 
by pressing on the abdominal wall until voluntary contraction 




Fig. 38g. 

has been acquired when this movement can be done without 
placing the hands over the abdomen (Plate II, Fig. i). 

Exercise II. — Patient lying on back, one hand across the 
abdomen, the other protecting the ring. Inhale and exhale 
without drawing in the abdomen. In this way, control of the 




Fig. 390. 

abdominal wall is obtained while the hernia is protected by 
placing the finger over the external ring. In most patients it is 
possible to teach them in one or two seances how to find the 
external ring and how to protect it in the various exercises (Fig. 
389)- 



PLATE II 




Fig. I. — ^Abdominal breathing, illustrating method of protecting the right abdominal rings 
by the second finger of the right hand held flat against the wall as in Exercise i. 




Fig. 2. — Position described in Exercise 4, showing the correct position of the legs and of 

the right hand. 




Fig. 3.- 



-Left side lying, showing right hand protecting the right abdominal rings, the sur- 
geon assisting in trunk flexion to the right. 



TREATMENT OF ABDOMINAL WEAKNESS AND HERNIA 467 



Exercise III. — Patient lying on back, one hand behind the 
neck, the other covering the external ring. Raise the head and 
shoulders, twisting in the opposite direction from the hernia. 
In this way the oblique muscles of the affected side are put 
into strong contraction, but if the movement be symmetric 
the rectus alone will receive 
the strain (Fig. 390). 





Fig. 391- 



Fig. 392. 



Exercise IV. — Patient lying on back, external ring protected. 
Without bending the knees raise both feet 6 inches from the 
table. Alternate the raising and lowering of the feet 12 inches 
five times without touching the table (Plate II, Fig. 2). 

Exercise V. — Patient lying on back, ring protected. Raise 
body from the lying to the sitting position, with the shoulders 
twisted so that the shoulder of the affected side is forward. 

Exercise VI. — Left side leg lying for hernia on right side. 
Left neck firm, right hand protecting ring. Side flexion of the 
trunk (Plate II, Fig. 3). 



468 



EXERCISE IN EDUCATION AND MEDICINE 



Exercise VII. — Patient standing, one hand protecting the 
ring, the other behind the head. Circumduction of the trunk, 
with the side bending from the affected side emphasized. 




Fife'- 393- 




Fig. 394- 



Where the ring is protected by a truss the arms may be placed 
in the neck firm position (Fig. 393). 

Exercise VIII. — Patient seated, hips firm, or, where a truss 



TREATMENT OP ABDOMINAL WEAKNESS AND HERNIA 469 

is worn, neck firm (Fig. 394). Backward bending and twisting 
right shoulder forward in a right hernia. 

Each exercise should he repeated twenty times. 

Exercise IX. — Massage, consisting of circular kneading 
movement, beginning at the external abdominal ring and passing 
upward and outward to the anterior superior spine. 

The general regulation of the physical life of these patients 
is also of importance. Perhaps the greatest mistake is to forbid 
all active exercise. There are few forms of exercise that such 
patients may not indulge in, not only with safety, but with great 
benefit. It may be laid down as a safe rule that the two things in 
exercise to be avoided are sudden and severe strain requiring the 
breath to be held, and, secondly, the maintenance of standing 
positions for long periods. One can engage in such games as 
tennis, golf, or even bowling, cricket, gunning, dancing, swim- 
ming, canoeing, and most forms of gymnastics without danger if 
reasonable precautions as to support are used, but one should 
avoid football, hammer throwing, jumping, riding, shot-putting, 
and wrestling. This last sport may be considered as the most 
dangerous exercise that could be taken by such patients. 

The exercise par excellence, recommended by Dr. Lucas 
Championniere in his admirable work on hernia, in which he also 
takes up the treatment by trusses and by operation, is bicycling, 
and he lays great stress on the fact that the weight is not sup^- 
ported by the legs, that there is no possibihty of violent and 
unsuspected strain, and the dose can be accurately indicated. 

The following are four t3rpical cases: 

Case A. — Mr. G., aged twenty-five, acquired a complete 
right inguinal hernia at five, coming on after a long and exhaust- 
ing walk. This remained down for several years, but under 
active exercise he has been entirely free from it ever since. 
The external rings on both sides are still larger than normal, 
admitting two fingers, but his muscular system is well developed, 
and he is able to go into the heaviest gymnastics without symp- 
toms. 

Case B.—Mr. K., aged twenty-three, at the age of twelve 



47© EXERCISE IN EDUCATION AND MEDICINE 

shortly after climbing and swinging in a tree noticed a visible 
protrusion, which remained in the same condition ever since. 
For five years he wore a truss, which had no curative effect, and the 
hernia remained much in its original condition up to the date of 
consultation. Walking made it painful, but he took part in games 
like baseball and canoeing without inconvenience. After three 
months' daily practice of the exercises described above he 
reported the hernia as retained without truss. The cure was 
confirmed a year later. 

Case C. — L. M. was referred to me three years ago by Dr. 
Robert G. Le Conte. The patient was fifty-four years of age, 
had a double hernia for ten years, but did not wish to undergo 
operation. He came to me wearing a truss, and after practising 
these exercises for six months the sense of insecurity left him and 
he dispensed with the truss, except during violent exercise. 
After three years his abdominal wall is in excellent condition, 
with no signs of return. 

Case D. — J. M. W., also referred to me by Dr. Le Conte, 
March, 191 1, complained of severe pains of a dragging character 
in the right inguinal region of three and one-half years' duration, 
during which time he wore a truss. He had to give up riding, 
walking, and golf, and' confined himself to office work. An ex- 
amination showed patulous abdominal walls and distended right 
external ring, with a distinct impulse on coughing. There was, 
however, no actual hernia. A course of three months with the 
exercises described banished these pains, and gave him a sense 
of security which has enabled him to take part in the many 
activities from which he has hitherto felt himself debarred. He 
has had no return of his symptoms. 

The prognosis for cure in these cases is about 70 per cent., 
according to Seaver, but the percentage would naturally de- 
pend largely on the care with which the cases are selected. 

The development of the muscular protection, which nor- 
mally prevents hernia, is the surest guaranty against its return. 



CHAPTER XXVI 



TREATMENT OF VISCEROPTOSIS AND CONSTIPA- 
TION, AND DISORDERS OF THE DIGESTION, 
BY MASSAGE AND EXERCISE 

The attainment of the upright posture is attended by the 
faults of posture already described, but any disturbance of poise 
invariably reacts on the con- 
tents of the abdomen as well. 
The fiat chest has as its sequel 
the protruding abdominal wall 
with its weak, flabby muscles. 
The drooping shoulders and re- 
laxed muscles are inevitably 
followed by the downward dis- 
placement of the abdominal 
organs and interference with 
their functions. In some cases 
this condition is congenital.^ 
The patient has never con- 
quered the mechanics of the 
upright posture, in which the 
chest is raised, the lower ribs 
flared out, and the abdomen 
flat. The organs are held in 
place normally by the cor- 
rect relative position of the 
chest wall and pelvis and the tonic contraction of the abdominal 
muscles. 

^ Joel E. Goldthwait, "Orthopedic Principles in the Treatment of Abdominal 
Visceroptosis and Chronic Intestinal Stasis," Surgery, Gynecology, and Obstet- 
rics, June, 1913, and "The Relation of Posture to Human Efficiency," Amer. 
Jour, of Orthopedic Surgery, vol. vii. No. 3; also "The Recognition of Congeni- 
tal Visceral Ptosis," Amer. Jour, of Orthopedic Surgery, November, igii. 

471 




Fig. 395. — Attitude of patient with con- 
genital visceral ptosis. Note downward in- 
clination of the ribs, backward inclination 
of the body, narrowing of the upper abdo- 
men, prominence of the lower abdomen 
(Goldthwait) . 



472 EXERCISE IN EDUCATION AND MEDICINE 

Above the last lumbar vertebra the abdominal cavity 
deepens, and each solid organ lies in its appointed place, the 
kidneys resting on their shelves are directed backward and 
upward, the liver is supported by the right kidney, by its peri^ 
toneal ligaments, and by the grasp of the lower ribs, the hollow 
viscera hang by their mesenteries also at their natural levels. In 
the flat-chested posture the shape of the abdominal cavity shows 
a pathetic change. The ribs are incHned downward and back- 
ward. The diaphragm moves down with them. The space be- 
neath it is lessened, and the liver and stomach are crowded down- 
ward. The ligaments are stretched, pressure is put on the kidneys, 
causing absorption of the retroperitoneal fat, and the organs, 
both solid and hollow, slide forward and downward to fill the 
new space made by the relaxing muscles and protruding ab- 
domen. The movable part of the colon is forced downward, 
and the hepatic and splanchnic flexures made sharp or even shut 
off, so that the contents are delayed and constipation results, 
while pressure is brought to bear on the uterus and ovaries, 
sometimes causing prolapse, often displacement, and always 
congestion. 

It is to correction of the poise that we must look to 
remedy these symptohis, and the special exercises for this 
purpose and the principles of the clothing required have already 
been illustrated, described, and discussed in the chapter on 
Postural Defects, although in many cases it is not possible by 
exercises alone to correct this condition when long standing. 

Goldthwait recommends the employment of a splint or 
brace to keep the parts in proper relation in the inter- 
vals of exercise and massage and to avoid fatigue for weak 
and debilitated cases. After becoming accustomed to this 
brace, exercises are begun in small doses and gradually in- 
creased until the correct poise can be maintained without undue 
fatigue or artificial aid. Resting should be taken in the kncc- 
c/icst or the prone-hanging positions, and recumbent exercises 
should be taken on the inclined table, with the head down, 
thus relieving the tension on the ligaments and allowing the 



TREATMENT OF VISCEROPTOSIS AND CONSTIPATION 473 

abdominal organs to find their way back to their proper place 
by the force of gravity (Fig. 396). 

Treatment must be carried on for a long time and the 
vicious habit replaced by the normal. Relapses are frequent 
unless the greatest care be taken to keep the clothing correct, 




Fig. 3g6. — Patient resting on Kellogg's inclined table with pad under the back, giving 
overextension of the spine and relief of pressure on the lower zone of the abdomen. 

build up the muscular powers, and impress correct habits of 
standing and sitting upon the child.^ 

CONSTIPATION 

Perhaps the most persistent symptom of these cases is. 
constipation, due partly to the blocking of the intestines, kinking 
at the angles of the colon, and partly due to the displacement 
and crowding on the lower zone. A general atony of the intes- 
tines accompanies weakness of the abdominal muscles, and 
goes far toward causing the lassitude, headache, and debility 
that attend it; but constipation may also be due to sedentary 
habits alone or accompanied by a faulty diet, and to neuras- 
thenia, anemia, and certain chronic affections of the liver, 
stomach, and the abuse of purgatives. It must also be remem- 

^ F. H. Martin, "Visceral Prolapse," Surgery, Gynecology, and Obstetrics, 
December, 1906; and Eliza Mosher, New York Journal of Gynecology and Ob- 
stetrics, November, 1893. 



474 



EXERCISE IN EDUCATION AND MEDICINE 



bered that constipation of an extreme degree may exist without 
other symptoms. Individuals differ greatly in this respect, and 
a careful inquiry should be made into the probable causes in all 
cases of constipation. About 12 per cent, of college students 
complain of it at their preliminary physical examination, due to 
sudden change of diet and occupation on leaving home, and in 
most cases a few simple exercises and the following hints on diet 
are sufficient to re-establish regularity. 




Fig 3Q7- — Deep rotating pressure massage (Gant). 



(i) Drink freely of water, a glass or more on rising and 
retiring. 

(2) Eat carrots, cabbage, lettuce, celery, turnips, asparagus, 
sterilized bran, and other bulky foods. 

(3) Eat grains, fruits, figs, prunes, and other laxative foods. 
Masticate thoroughly. 

(4) Avoid fried foods, meat overdone, hard-boiled eggs, 
pastry, and much sugar. 

(5) Cultivate habits of regularity in hour of evacuation. 
When the causes are complicated and the condition per- 
sistent all the resources of exercise should be brought to bear 



TREATMENT OF VISCEEOPTOSIS AND CONSTIPATION 



475 



on the case, as well as regulation of the diet and even the 
use of mineral waters or other light laxatives. 

The application should be in the form of massage, vibration, 
dupHcate and active movements, and the cultivation of regular 
and systematic habits. The massage should be very deep and 
slow, following the course of the colon, beginning in the right 
iliac region, passing upward to the ribs, across the abdomen, 
just above the umbilicus, and down the left side, terminating in 
deep, slow, circular movements in the left iliac region over the 
sigmoid flexure and the rectum. These kneading move- 
ments should be done very slowly, with firm, deep, and 




Fig. 398. — Abdominal massage. 



insistent pressure, the knees of the patient being drawn up and 
the abdominal walls relaxed. 

When there are impacted feces the movement should begin 
over the sigmoid, with the object of breaking up the mass in this 
region first. The tips of the fingers of one hand can be used (Fig. 
397) in a series of jerking, circular pressure, friction movements, 
done not too quickly, and following this the descending colon 
should be kneaded between the hands, one well behind and 
the other in front of the abdomen, the heel of the hand making 
the pressure (Fig. 398). 

The reflexes can be stimulated also by light tapotement 
along the margin of the ribs throughout the entire costal angle 



476 



EXERCISE IN EDUCATION AND MEDICINE 



from right to left (Fig. 399), and along the spine with deep 
tapotement from the eighth to the twelfth dorsal. The ad- 
ministration of tapotement or vibrations along both sides of 
the spine from the first to the fouth lumbar will alone give 
immediate relief in some cases. 




Fig. 399. — Tapotement of rib margin. 

Graham recommends self-percussion with the ulnar border of 
the fist night and morning for several minutes (Fig. 400) . Massage 
must be deep and insistent or the effects will be negligible, ex- 
cept to irritate the skin to 
no purpose. 

A cannon-ball covered 
with chamois leather has 
been used for the same pur- 
pose, and most sanatoriums 
have the Zander machine, 
on which the patient lies 
face downward, the abdo- 
men resting on a loose 
leather diaphragm, beneath 
which a ball set in motion 
by a motor follows the 
course of the colon, giving 
continuous upward pressure. These movements are not so effect- 
ive, however, as the trained human hand. 




Fig 400.— Self-percussion over the subcostal 
region. 



PLATE III 




Fig. I. 




Fig, 2. 



TREATMENT OF VISCEROPTOSIS AND CONSTIPATION 477 

Massage alone is scarcely ever sufficient in the treatment of 
constipation, and certain active movements are necessary to 
supplement the more passive forms. 

Among the exercises that have proved of value may be 
cited the turning of the nautical wheel (Fig. 255) and the trunk 
rotation, described in the exercises for abdominal weakness 
(Figs. 391, 392, 393, 394). 

Two additional exercises may be described that act directly 
by pressure on the abdominal contents: 

Exercise I. — Patient lying supine on a couch, arms at the 
sides. Raise the right leg with knee bent. Clasp the hands over 
it and press it against the abdominal wall. Repeat with the left 
(Plate III, Fig. i). Repeat twenty times. 

Exercise II. — Patient astride a plinth, arms behind the 
back. Trunk circumduction, bending well forward to the right, 
then forward, and then to the left (Plate III, Fig. 2). Repeat 
twenty times. 

Circumduction of the pelvis is given most effectively by 
Zander's camel, the patient sitting on an excentrically moving 
saddle, or on the horse which is a substitute in movement for 
the trot, and riding on horseback itself is to be strongly recom- 
mended when available. 

In cases due to sedentary life a game of golf or a walk of 
a couple of miles over uneven ground may be enough, and deep 
respiratory exercises are of great value through the automatic 
massage given the abdominal contents by the excursion of the 
diaphragm and abdominal walls. 

Jueltner^ advises his patients to drink several glasses of 
fresh water immediately after rising in the morning. In some 
cases hot water with a little salt answers better, this to be 
followed by a brisk half-hour walk. The patient takes a rather 
light breakfast, laxative in character, followed by a fifteen-min- 
ute walk. After this he makes a determined effort to defecate. 
If unsuccessful, he irrigates the colon at night, the patient lying 
on the back with knees drawn up; then beginning at the left 
1 Journal of Advanced Therapy, New York, 1905, xxiii, 446. 



478 EXERCISE IN EDUCATION AND MEDICINE 

iliac space, he gently kneads along the course of the descending 
transverse and ascending colon, to distribute the water and 
soften the fecal matter and stimulate peristalsis. Savage^ advo- 
cates one exercise in which the patient hangs head down by the 
knees on a ladder; he also advises leg circles in the lying and 

standing position. 

GASTRITIS 

In advising massage or active movements for cases of .chronic 
gastritis great care should be taken, as in diabetes, to stop all 
exercise before reaching the point of exhaustion, because bodily 
as well as mental fatigue may be one of the causes of the condi- 
tion, and it nearly always aggravates it. For this reason mas- 
sage is preferable to any but the mildest exercises. 

In nervous dyspepsia, which is so frequently a symptom of 
neurasthenia or hysteria, the rest cure of Weir Mitchell, with 
careful regulation of the diet, massage, and light resistive exer- 
cises leading on to more active movements are useful. In all 
such cases of gastritis massage should be given about two hours 
after a meal, and should include pressure and kneading of the 
hj'pochondriac and epigastric regions from left to right and down- 
ward. 

These movements give immediate relief in some cases. They 
force the stomach contents into the duodenum, stimulate the 
action of the Hver, and alternately compress and relax the gall- 
bladder. They should be followed by kneading along the course 
of the colon, and vibratory massage over the spine, from the 
fourth to the tenth dorsal, whenever tender points can be made 
out. The reHef from the feeling of oppression and the more dis- 
tressing s}Tnptoms so frequently present m these conditions is 
often rapid and complete. 

Light tapotement with the finger-tips along the costal margin 
on the left side from the tenth to the sternum and down the 
right side to the tenth will be followed by contraction of the 
dilated stomach- (Fig. 399). 

' Journal of Advanced Therapy, New York, 1904, xxii, 736. 
^ Percy Mitchell, Lancet, Januar}- 28. 191 1. 



CHAPTER XXVII 

TREATMENT OF RESPIRATORY DISEASES BY 
EXERCISE AND FORCED RESPIRATION 

The bacilli of tuberculosis are so nearly omnipresent that 
practically all are infected from time to time, and the develop- 
ment of the disease depends on the nature of the soil offered by 
the individual and on the activity or inactivity of the respira- 
tory tract. The level of resistance and vitality must be raised 
if infection is to be successfully resisted, and this can be done 
best by improving living conditions, supplying good food, good 
air, and sufficient exercise. As already pointed out, the school 
cannot provide sufficient corrective exercise for all forms of dis- 
ease amenable to such treatment. It should provide correction 
for the defects brought on by school life, and should, by good 
ventilation and frequent spells of corrective exercise, build up 
those powers that will help the pupils to throw off the constant 
infection to which they are subjected. This, in conjunction 
with the playground conducted by the school or city, should 
provide the exercise necessary for prevention. 

In the college cases of incipient tuberculosis should be de- 
tected on entrance and individual treatment begun. In 8 cases 
discovered last year at the medical examination, which is given 
to all men entering the University of Pennsylvania, treatment 
was begun at once, and only one. man was compelled to give up 
the course, which would have become impossible for all of them 
had their cases been neglected. 

There is a responsibihty then resting on school and college 
for the prevention of this disease, for its discovery when present, 
and sometimes for its care and treatment in incipient stages. 

CiviKzation has made an outdoor life impossible for most of 

479 



480 EXERCISE IN EDUCATION AND MEDICINE 

US, but the construction of outdoor sleeping porches and other 
such devices make it possible for indoor workers to sleep under 
conditions that approach out of doors so far as fresh air is con- 
cerned. 

Many people have the idea that the more they exercise the 
quicker they will get well from tuberculosis. For this reason 
many young men are instructed to take part in violent athletic 
sports as a remedy, and the exhaustion following hard rowing, 
football, or running goes far to hasten the course of the disease. 

Many tubercular young men have a peculiar muscular in- 
telligence which makes them brilliant athletes, just as the 
mental alertness sometimes seems to be increased by the dis- 
ease, and for this reason athletics are frequently blamed for 
causing tuberculosis when they have been mistakenly prescribed 
as a treatment. No patient should be allowed active exercise 
who has lost one-fourth of his weight, who. had a temperature 
of 100 at any time during the day, or if light work sends his 
pulse above no. Rest is more important than work in these 
cases. "The healthy man sits down because he is tired. The 
consumptive should sit down so as not to become tired" 
(Brehmer). 

Overexertion of any kind is poison. The acceleration of the 
pulse, perspiration, palpitation, rise of temperature, feeling of 
weakness, discomfort, and headache are all signs that he has 
overstepped the safety limit. 

Just when exercise should be begun should be decided only 
by testing the patient. A bad effect is shown by an increase in 
temperature, rapid heart, loss of appetite, an increased cough 
and expectoration, or by a hemorrhage. Any of these occur- 
rences would show that the rest period should be continued, 
except possibly when only an increased rapidity of the pulse 
results. A patient who shows no disadvantage from exercise, 
except an increased heart action, should take graduated walks 
to strengthen the heart. In other words, a long-rested heart 
must be trained gradually to acquire sufficient strength to allow 
the patient to work. 



TREATMENT OF RESPIRATORY DISEASES 48 1 

The first exercise a patient should take is a sponge bath in the 
morning, first with tepid water, later with cool water, and, finally, 
often with cold water to be followed by a brisk rubbing with a 
towel until the skin is aglow. The warmer the skin is and the 
better the circulation in the skin, the less likely is the patient 
to become chilled or take cold. 

The next exercise should be ordinary walking, graduated 
according to his strength, to educate his heart to endure in- 
creasing muscular work. 

Next comes calisthenics or games that require more or less 
exertion, and finally some light labor. Driving or automobile 
riding may also be advantageous if facilities are offered. 

Breathing exercises or lung gymnastics are to be used with 
the greatest caution. The tuberculous lesion heals by contrac- 
tion and not by expansion. Persons who have no active tuber- 
culosis, who are insufficiently aerating their lungs, who are 
becoming hollow-chested and whose breathing is shallow, should 
take deep-breathing exercises, but a patient undergoing a cure 
for tuberculosis of the lungs should not. A patient receiving 
tuberculin treatment should also be at rest; that is, he should 
not take exercise on the days of the injections.^ 

It is always of advantage to arrange a patient's daily rou- 
tine if he is out of bed. He should have his meals and inter- 
mediate nutriment at regular intervals. He should have such 
rest times and such exercise times as prescribed, and he should 
retire at the hour ordered. It is also well to know absolutely 
what his exercise is, what his play consists of, and how absolute 
is his rest. 

Some sanatoriums endeavor to offer some simple, self- 
sustaining work so that patients may pay for their treatment 
at the same time that they take the cure. Such facilities allow 
an impecunious and partially healed patient to remain long 
enough to perfect his cure. 

In the treatment of pulmonary tuberculosis the place of ex- 

1 Edward O. Otis, "Use and Abuse of Pulmonary Gymnastics," Boston Medical 
and Surgical Journal, vol. civ, 3. 

31 



482 EXERCISE IN EDUCATION AND MEDICINE 

ercise has been well defined by Kinghorn,^ who, after speaking 
of the open-air treatment and the treatment by rest, advises the 
patient to begin with walking at first on level ground for ten or 
fifteen minutes every second day for several weeks, then every 
day for several weeks, and at last twice a day. When the patient 
stands these little walks without harm, and when the weight in- 
creases or holds its own, the exercise may be extended under 
careful supervision, but hard mountain clmibing should never be 
pemiitted. 

In cases where no lesion can be found, but where the tend- 
ency is shown by the history of exposure to infection, by family 
history, or by the formation of the chest, much good may be 
expected from open-air exercise accompanied by training of the 
respiratory powers. Deep breathing is a muscular act capable 
of education, and the capacity of the lungs or mobility of the 
thoracic walls can be increased as well as the strength of any other 
part of the muscular system, while the general circulation, the 
skin, the appetite, and the digestion all share in the heightened 
activity, and healthful sleep is insured by the resultant moderate 
fatigue. Exercise for this purpose should be general and special. 
Singing and elocution lessons are valuable, and the practice on a 
wind instrument has been recommended. Running and climb- 
ing are of the greatest value for increasing the breathing capacity 
if kept withm the Hmits of fatigue. 

Daily supervised exercises are necessary to increase rapidly 
the power of chest expansion and vital capacity. They should be 
directed to a framing in the best methods of breathing, to de- 
veloping the chest and abdominal muscles, and should be pre- 
ceded and followed by accurate measurements and spirometer 
records. All exercises should be prescribed in writing, with 
the most minute directions as to time, frequency,, and severity, 
and a record of the patient's weight should be kept and fre- 
quent examinations made to determine his progress, a rapid 
loss of weight being followed by a reduction or abandonment 
of exercise. They should include both active, duplicate, and 
^ Montreal JNIedical Journal. 



TREATMENT OF RESPIRATORY DISEASES 483 

passive movements, but it must be remembered that however 
deep the respiratory movement may be, the amount of oxygen 
absorbed is only in proportion to the need of the body. The 
oxygen in the blood remains measurably constant, and the only 
way to increase its absorption by the tissues is to do work that 
causes the breaking down of oxygen compounds. Deep breath- 
ing would result naturally from more demand, but would not 
create this demand. Its role will be to strengthen the intrinsic 
and accessory muscles of respiration, to teach the co-ordination 
necessary for deep breathing, and to massage the abdominal 
contents by wider excursions of the diaphragm. 

Enforced deep breathing for a period of several minutes 
materially increases the length of time the system can do with- 
out respiration, serves as an effective mental stimulant, and 
raises the frequency of the pulse-beat. Violent deep breathing 
for several minutes so overcharges the system with oxygen as 
to make respiration unnecessary for perhaps as much as five 
minutes after this preparatory breathing is over. 

In one case, four minutes of enforced breathing made it pos- 
sible to hold the breath for nearly four minutes, whereas without 
this preparation fifty-six seconds was the limit. The time during 
which it is possible to do without respiration increases, of course, 
with the length of time during which the preparatory breathing 
is carried on. The increase does not go on indefinitely, but reaches 
a definite limit, beyond which further length of time given to 
preparatory breathing does not increase the time which the 
breath may be held. Below is one series of experiments: 

A — Length of time in minutes devoted to deep breathing. 

B — Time in minutes and seconds during which the breath was held after preUminary 
breathing was stopped. 

A T 5 f 3 I 2 3 4 

B 0.56 1.24 1.39 1.54 2.12 3.00 3.26 3.54 

The preparatory breathing is effective long after the wash- 
ing out of the lungs has been completed. There is a mild tem- 
porary intoxication of the entire system. The effect as a 



484 



EXERCISE IN EDUCATION AND MEDICINE 



mental stimulant is very pronounced. Mental fatigue may be 
postponed beyond the usual point by two minutes of rapid 
breathing at half-hour intervals, and a feeling of sluggishness 
or sleepiness may be almost completely dispelled. The effect 
on muscular fatigue is also striking. A difficult arm exercise 
with heavy weights, which could not be repeated under or- 
dinary circumstances more than twenty times, after a few 
minutes of this preparatory deep breathing could be performed 
twenty-seven times; this is about 30 per 
cent. more. The pulse-beat goes up very 
rapidly while the breathing is continued — 
in the case quoted above from 65 to 106 
beats after four minutes of breathing. 

Deep breathing alone repeated a number 
of times during the day may be useful, and 
its practice should be made part of every 
day's regime in those cases in which there is 
no danger of overstretching an active lesion 
and bringing on a hemorrhage. 

Turbaus' method is to take ten to twenty 
deep breaths five to ten times daily, the 
patient reclining. 

The normal respiratory act is a compos- 
ite of two distinct types of breathing — (i) 
thoracic and (2) abdominal. 

The thoracic type predominates almost 
to the suppression of the other among all, 
irrespective of sex, who wear constricting 
clothing about the waist line, and the first care must be to re- 
establish control of the diaphragm and abdominal walls. The 
following exercises should be practised before a mirror: 

Exercise I. — Patient standing. Place the hands across the 
abdomen. Inhale deeply. Exhale by pressing on the abdominal 
wall, keeping the thorax fixed in the position of inspiration 
(Fig. 401). Repeat this movement five times slowly with the 
thoracic wall fixed, using the movement of the abdominal walls 




Fig. 401. 



TREATMENT OF RESPIRATORY DISEASES 



485 



only. Rest. After a little practice this movement should be 
done with the hands at the sides. 

Exercise II. — Patient standing. Place the hands across the 
abdomen. Inhale forcibly by pushing out the abdominal walls, 





Fig. 402. — Inhalation — abdominal. 
The abdomen is protruded without ex- 
panding the thorax. 



Fig. 403. — Exhalation — abdominal. 
The abdomen is indrawn and the breath 
expelled without contracting the chest. 



keeping the thoracic wall fixed as in expiration. Exhale by draw- 
ing in the abdomen. Repeat five times slowly. Rest. As soon 
as control has been obtained, practice this exercise with the 
hands placed behind the back (Figs. 402, 403). 





Fig. 404. — Thoracic breathing — inhalation. 



Fig. 405. — Thoracic breathing — exhala- 
tion. The girth of the abdomen remains 
unchanged. 



Exercise III. — Patient standing with the hands across the 
abdomen. Inhale forcibly, using the thorax only, without 
movement of the abdominal wall. Repeat five times slowly and 



486 



EXERCISE IN EDUCATION AND MEDICINE 



rest. As soon as control of the abdominal walls has been ob- 
tained do this exercise with the hands behind the back (Figs. 
404, 405). 

Thoracic breathing can be forced still further and the walls 
of the chest stretched by using the arms in the following ex- 
ercise : ' r 

Exercise I V. — Patient stand- 
ing with the arms at the sides. 





Fig. 406. Fig. 407. 

Raise both arms forward (Fig. 406) until they are above the 
head, inhaling. Hold the breath and stretch upward. Rise on 
tiptoes (Fig. 407). Lower the arms sideward, pressing back- 
ward and exhaling (Fig. 408). Repeat twenty times at the 
rate of about five to the minute. 

Patients will sometimes have a feeling of dizziness, and may 
even stagger and fall at the sudden change of the blood-pressure 
in the head, but this need cause no alarm. 



TREATMENT OF RESPIRATORY DISEASES 



487 



Exercise V. — Patient standing with the arms at the sides. 
Raise both arms sideward, pressing back and inhaUng (Fig. 409) 




Fig. 40S. 



Fig. 4og. 




Fig. 410. 

until they are above the head. Hold the breath and bend for- 
ward, keeping the knees straight, until the hands touch the 
floor (Fig. 410). Rise, keeping the arms above the head. Lower 



488 EXERCISE IN EDUCATION AND MEDICINE 

the arms sideward, pressing backward and exhaling. Repeat 
twenty times at the rate of five to the minute. This exercise 
compresses the air on the lungs and forces it into the cells that 
are Httle used in ordinary breathing. 

The following duplicate and passive movements may be em- 
ployed for increasing the chest mobility and improving the 
respiration. 

Exercise VI. — Patient lying supine on a plinth with- feet 
fixed, arms bent, and palms up. The surgeon grasps the hand, 




Fig. 411. — Artificial respiration. Surgeon pulling up and patient resisting. 

palm to palm, and pulls upward to full extension of the arms, 
the patient resisting (Fig. 412). The patient then pulls downward 
and forward to the first position, the patient resisting. Inhale 
as the arms go up and exhale as they come down. 

Exercise VII. — Patient lying supine on a plinth, the lower 
part of the thorax supported by a roller 4 inches high, the arms 
behind the head, and the chest expanded in inhalation. The 
surgeon presses on both sides of the lower thorax, directing the 
patient to exhale (Fig. 413). Repeat twenty times at the rate 
of about ten to the minute. 



TREATMENT OF RESPIRATORY DISEASES 



489 



Schaefer's method of artificial respiration is of use to make 
more resiliant the chest walls, and Weinlander describes a 




Fig. 412. — Stretching of the thorax by traction on the arms in the movement of artificial 

respiration. 




Fig. 413- 



method used in resuscitation that could in some selected cases 
be employed to stretch the chest walls: 



490 EXERCISE IN EDUCATION AND MEDICINE 

The patient is placed supine, with the head over the end of 
the table. He grasps the arms at the elbows, pushes them up 
and back toward the back of the head, thus drawing on the pec- 
toral muscles and ribs and inducing powerful inspiration. The 
grasp is released and the arms swing down, the chest wall relax- 
ing. This is repeated to the rhythm of about twelve to the 
minute. 

A valuable exercise is that given by Zander's machine, known 
as the tower, in which pressure is placed on the back by a cush- 
ioned pad and the shoulders are drawn upward and backward 
rhythmically with the respiration (Fig. 317). 

While the effects of breathing exercises are excellent, the 
patient loses interest only too often in movements taken alone 
and without supervision. Pescher has invented a simple and 
practical method for stimulating the patient's interest and fol- 
lowing his progress, which he described at one of the recent 
meetings of the Societe de I'lnternat des hopitaux de Paris. A 
bottle filled with water and inverted in a receptacle containing 
a little water does not empty itself on account of the pressure of 
the atmosphere; but by blowing into the interior of the bottle 
through a tube, a volume of water is displaced about equal to 
the amount of air introduced. This is the principle of the wet 
spirometer. By the use of bottles graduated to all capacities 
this exercise can be prescribed in progressive amounts in accord- 
ance with the condition of the patient's lungs. 

The patient is made aware from day to day of his progress, 
not only subjectively, but objectively. He begins with recep- 
tacles of medium capacity, \ liter in the case of children and 
I liter with adults. He goes as far as 2 or 2\ liters with children 
and 4 to 4^ liters with vigorous adults. Inspiration should be 
made through the nostrils and should be slow and rhythmic. 
After each exercise of inhalation and exhalation he should rest 
for a time equal to that taken in the exercise. From ten to one 
hundred exercises should be done two or three, or perhaps four, 
times in every twenty-four hours. They should be taken not 
less than one and one-half hours after eating. Ten exercises done 



TREATMENT OE RESPIRATORY DISEASES 49I 

carefully require about one-quarter of an hour. Those who get 
the most benefit from the exercises are narrow-chested children 
— those who have difficulty in respiration — the pretuberculous, 
and even the tuberculous. 

The effects of deep-breathing exercises alone are tonic and 
stimulating and have a marked effect on the weight. Richter, 
in his classes for voice-training, uses deep-breathing exercises 
as a routine measure. He finds that in two and one-half months 
there was an average gain of 9 pounds in a whole class of students, 
attributable almost entirely to the increased respiratory activ- 
ity. In my own practice on scohotic patients it is not un- 
common to see an increase of 30 per cent, in the lung capacity, 
indicating a greater reserve movement and control in the ab- 
dominal and thoracic walls, and in the diaphragm, which is of 
undoubted value in all conditions requiring respiratory power. 

Butler, of Brooklyn, has reported many cases of incipient 
phthisis in which deep breathing has been used as an accessory 
to overfeeding and rest, with marked improvement in weight 
and general health, but one must never forget that when the 
disease is active in the lung, deep breathing will only irritate and 
aggravate what nature attempts to splint by limiting the move- 
ment over the affected area, and in some cases a hemorrhage 
may be brought on from the ruptured walls of a cavity. 

Hofbauer has devised an apparatus to record the expiration, 
neglecting inspiration. This stresses the expiration phase of 
breathing, and has been found extremely useful in curing em- 
physema and asthma. In some of the worst chronic cases a 
complete cure was realized with no recurrence.^ 

RosenthaF gives the details of 19 cases of primary tubercu- 
lous pleurisy, in which great benefit was derived from respiratory 
exercises. They are a powerful means of influencing both the 
acute phase and convalescence of serofibrinous pleurisy while 

1 L. Hofbauer, "Exercises to Strengthen Expiration in Treatment of Asthma," 
Die Summtherapie des Bronchilasthmas. 

^ "Physiologic Respiratory Exercises in Serofibrinous Pleurisy," Archives 
Generales de Medicine, Paris, xlix, no. i. 



492 EXERCISE IN EDUCATION AND MEDICINE 

entirely harmless if done cautiously. The exercises should be 
unilateral, progressive, diaphragmatic, supplementing the ordi- 
nary measures during the acute phase and beginning with five 
or ten respirations through the nose with the patient reclining. 
The active dose is from forty to sixty respirations in series of 
ten. During convalescence these exercises can be repeated 
from three to seven times a week. These exercises counteract 
the tendency to adhesion of the pleura and to chronic pneu- 
monia and local sclerosis. If supervised and kept up, the patients 
do not develop pulmonary tuberculosis later. The chest measure 
soon shows the benefit derived. 

In the application of respiratory exercises every attendant 
condition should be made as favorable as possible at all times to 
get the best therapeutic results. Fresh air should be supplied 
in abundance, and treatment should be given in the open air or a 
well-ventilated room, for many of the disorders of the respiratory 
tract are due to the impurity rather than to the temperature of 
the air breathed. 

In a letter to Miss Shipley from Benjamin Franklin, he an- 
ticipated the modern sleeping porch so widely used by a fanciful 
story in which an angel comes to Methusalem and says, "Arise 
Methusalem, and build thee a house, for thou shalt live yet five 
hundred years." And Methusalem answered and said, 'Tf I am 
to live but five hundred years it is not worth while to build me 
a house, I will sleep in the air as I have been used to do"; and 
he concludes with the hope that we may be cured of the aero- 
phobia that at present distresses weak minds and makes them 
choose to be stifled and poisoned rather than leave open the 
window of the bed-chamber or put down the glass of a coach. 



CHAPTER XXVIII 

EXERCISE IN THE TREATMENT OF DISEASES OF 
THE CIRCULATION 

The heart is a muscle capable of development and liable to 
overwork, and the arterial system shares intimately in changes 
taking place in the central organ of the circulation. 

The heart may suffer from: 

(i) Acute or chronic overstrain with dilatation, hypertrophy, 
and leaks at the valves. 

(2) The accumulation of fat in the walls and pericardium. 

(3) A slow hardening and degeneration of the heart wall and 
a lessened resiliency of the arteries with increased blood-pressure, 
known as arteriosclerosis. 

(4) Anginal attacks, accompanying dilatation and caused 
by bodily or mental overexertion, frequently associated with 
arteriosclerosis. 

(5) Actual distortion of the valves due to inflammatory 
action, associated with acute rheumatism, chorea, and certain 
other acute diseases. 

In the fifth class the valves may become crumpled and the 
orifice reduced in size, causing stenosis, or the flaps may fail 
to meet, the blood-stream leaking back when the contraction 
of the chamber walls is over; and sometimes both conditions 
may exist in the one valve, each of these defects giving rise to a 
characteristic sound or murmur. 

In the order of their seriousness, valvular defects may be 
classified as, first, and least dangerous, stenosis of the aortic 
valve (Fig. 414), overcome by a compensating thickening of the 
left ventricular wall; second, mitral insufficiency (Fig. 415), 
the blood regurgitating into the left auricle through an im- 

493 



494 



EXERCISE IN EDUCATION AND MEDICINE 



perfect closure of the valve between it and the left ventricle 
during systole, causing overdistention of the left auricle, pul- 




s D s D s D s 

Fig. 414. — Endocardial heart-murmur. Stenosis of the aorta. A systolic murmur in 
the right second intercostal space (Vierordt and Stuart). 

monary circulation, and right heart; third, stenosis, or narrow- 
ing of the mitral valve (Fig. 416), followed by an increase in 





s D s D s D s 

Fig. 415. — Endocardial heart-murmur. Mitral insufficiency. A systolic murmur at 
the apex of the heart (Vierordt and Stuart). 

wall thickness and dangerous dilatation of the left auricle, 
embarrassment of the pulmonary circulation and right heart; 




s D s D s D s 

Fig. 416. — Endocardial heart-murmur. Mitral stenosis. A diastolic murmur at 
the apes, the first sound valvular or approximately so, if the second sound is heard at 
all (Vierordt and Stuart). 

and last, insufficiency of the aortic valves (Fig. 417), which 
throws such an increased burden on the left ventricle that any 




s D s D s D s 

Fig. 417. — Endocardial heart-murmur. Aortic insufficiency . A diastoHc murmur 
at right second intercostal space or, better, lower down to the left of this over the sternum 
(Vierordt and Stuart). 

overstrain is liable to be suddenly fatal. This last condition is 
the usual consequence of the first, since the hypertrophy result- 



EXERCISE IN TREATMENT OF DISEASES OF CIRCULATION 495 

ing from aortic stenosis soon gives place to dilatation of the 
aortic orifice and consequent regurgitation of blood in the left 
ventricle. The following table^ shows the blood-pressure changes 
in most common cardiac affections. In combined lesions the 
change is usually that of the lesion that predominates. The 
normal pulse pressure is about one-third the systolic pressure.^ 

Nature of disease. Systolic pressure. Diastolic pressure. Pulse pressure. 

Aortic incompetence Very high. Low. Much increased. 

Aortic stenosis Low. Relatively high. Much decreased. 

Mitral stenosis with cyano- 
sis High. High. Decreased. 

IMitral incompetence Variable. Variable. Variable. 

Heart-block Very high. High. Much increased. 

Dilated heart. Low. Low. Decreased. 

The physician in treating structural disease of the heart 
should be more interested in the ability of the heart muscle 
to do its work than in the structural changes of the affected 
valve. The heart muscle, if kept in a healthy state, will com- 
pensate for a damaged valve by doing extra work, and the 
function of all organs will be performed in a normal manner. 
So long as this compensation is complete the patient is, physio- 
logically speaking, not diseased, and Sutherland has pointed out 
the frequency of irregular heart action and the occurrence of 
movements without other symptoms in young children.^ 

The heart takes part in a general strengthening of the muscu- 
lature, and the proper use of rest and exercise as well as diet 
is of the utmost importance.^ 

In the chapter on Physiology of Exercise it was explained 
that by exercises of effort the blood-pressure was suddenly 
raised to nearly double the normal, falling quickly to its usual 
level with the cessation of the action; by exercises of endurance 
the rise of the blood-pressure followed the rise of pulse-rate, 

^ Table by G. A. Gordon, Edinburgh Medical Journal, January, 1910. 

" Francis Ashley Faught, " Relationship and Value of the Systolic, Diastolic, 
and Pulse Pressure," N. Y. Med. Jour., Feb. 27, 1915. 

^ G. A. Sutherland, The Heart in Early Life. 

* Joseph H. Pratt, M. D., "The Advance of Physical Therapeutics," Inter- 
national CHnics, vol. iv. 



496 EXERCISE IN EDUCATION AND MEDICINE 

gradually declining until the end of the test, when it fell to sub- 
normal and slowly recovered. Accompanying tests of either 
effort or endurance there is always a temporary dilatation of the 
heart as a matter of economy, and it is only when the dilatation 
becomes excessive and is accompanied by greatly decreased 
blood-pressure that harm results. The marked acceleration of 
the onset of fatigue and the slow recovery in the untrained Or 
overtrained man is familiar to all who have seen such cases after 
violent and prolonged exertion. The difference between one 
acute overstrain and the continuous overtaxing of the circula- 
tory apparatus was also explained. When the heart walls have 
acquired a certain degree of rigidity overstraining may produce 
permanent deterioration by breaking up the elastic fibers and 
causing the characteristic lesions of arteriosclerosis. 

Arteriosclerosis must be expected among those in whom hard 
and exhausting labor is carried on for long hours under unsanitary 
conditions, among the mentally overworked, in whom worry and 
exhaustion is habitual, and in those whose advancing age and 
hardening tissues do not permit of the rapid recovery from 
overstretching that is found in the normal healthy youth. It 
is said to be the cause of death elected by great men, and the 
roll of its victims contains many distinguished names. 

This obscure and ill-understood disease is ascribed to habitual 
overstrain of the heart, either from the excessive use of alcohol, 
overeating, continued mental strain, or from prolonged muscular 
overwork. It was first described by Peacock, about thirty-five 
years ago, as a result of observations made by him on Cornwall 
miners, who are especially subject to continual severe muscular 
strain. His observations have been confirmed by the investiga- 
tions of Myers, Sir Chfford Allbutt, Da Costa, and others. 

Arteriosclerosis is characterized by hypertrophy of the heart, 
high tension of the pulse and wide pulse pressure, rigidity of the 
walls of the blood-vessels, and the formation of calcareous de- 
posits in the arterial walls. The process seems to begin by a 
breaking up of the elastic fibers of the vessel walls and the forma- 
tion of scar tissue, which finally becomes calcareous. In the con- 



EXERCISE IN TREATMENT OF DISEASES OF CIRCULATION 497 

dition of atheroma the artery becomes hard and feels h'ke a string 
of beads under the finger. The cause of this lowered nutrition in 
the vessel walls has been ascribed by Sir Lauder Brunton to the 
diminished pulsation of the vessel wall, caused by the high tension 
and the loss of the normal massage which produced in them a 
constant interchange of the lymph in the encircling sheath. Each 
time that the artery is dilated by the blood forced into it by the 
heart-beat the lymph is driven out of this sheath, while with the 
following contraction of the artery more fluid again flows in 
(Fig. 418). It is evident, he says, that if the difference between 
the size of the artery in expansion and contraction is great, 
there will be a correspondingly free circulation of lymph in the 
sheath of the vessels, but if the difference is very small the 
movement of the lymph will be slow and imperfect, the oscilla- 
tion of the vessel being diminished, and it is a fact that con- 





Fig. 418. — Diagram of the effect of the arterial pulse in aiding the circulation in the 
veins and self-massage of the artery: A is the artery, V the vein, and 5 the fibrous sheath 
which encloses them both, and also a lymph-space, which is shaded in the diagram. A 
shows the artery contracted during cardiac diastole with the vein distended with blood, 
and the space with lymph; A' is the artery distended with blood by the cardiac systole, 
which at the same time drives the venous blood along and empties the lymphatic space 
(Sir Lauder Brunton). 

tinned high tension within the arteries leads to arteriosclerosis, 
to degeneration of the vessels, fibrosis, and atheroma, with 
increased liability to rupture causing apoplexy, or to cardiac 
hypertrophy and subsequent degeneration. 

Prolonged muscular overwork may act as a cause of this 
condition by throwing into the circulation the products of 
muscular waste, particularly hypoxanthin, which itself, when 
injected into the vessels experimentally, will produce abnormally 
high-tension and atheroma. The continual presence of a sys- 
tolic pressure of over 150 mm. of mercury must always be 
regarded with suspicion. When the diastolic pressure is low the 
32 



498 EXERCISE IN EDUCATION AND MEDICINE 

suspicion of arteriosclerosis will be strengthened, and if the radial 
pulse cannot be entirely obhterated by pressure of the finger 
it will be confirmed. 

Exercise Treatment. — The aim of exercise is to reduce a high 
pulse-rate by flushing the peripheral vessels, to postpone the onset 
of breathlessness by deepening the respiration and improving 
the muscular tone of the heart, to remove the encumbering fat 
which muffles its movements, and to prevent palpitation by 
acting both directly and indirectly on the cardiac nerves. For 
this purpose, exercises of effort and of endurance each have had 
their advocates. 

Exercises of effort have been employed from the time of 
Ling to the present, with such advocates as Stokes, Bezly 
Thorne, Heineman, Groedel, S after thwaite, and the brothers 
Schott at Bad Nauheim. They have always been confined to 
single efforts of the most simple kind with rests between, accom- 
panied by massage and combined with regulation of diet and the 
administration of simple and carbonated brine baths. 

It is in the method of giving and the dosage of exercise that 
authorities differ. Wide recommends kneading, rolhng, and 
respiratory movements. He uses abdominal massage which, 
according to Levin's researches, can reduce an overexcited 
heart-rate, while Schott and others claim that abdominal massage 
should be prohibited, because it tends to inhibit the heart's 
action and so prevent aeration of the blood. Kellogg obtains 
good results from electricity in very fat patients by applying the 
sinusoidal current to different regions, and thus exercising the 
muscles without the exhaustion of voluntary effort. 

All movements of the extremities, especially the legs, draw 
the blood out from the heart and abdomen and act as depletive 
influences. The back trembling given by Zander's vibrator 
has a powerful influence in reducing a rapid pulse, as have 
vibrations given along the back from the first to the fourth 
dorsal, or tapotement over the first dorsal. These procedures 
have the added advantages of being apphcable to a patient who 
is bedridden, and to whom movements of the arms and legs must 



EXERCISE IN TREATMENT OF DISEASES OP CIRCULATION 499 

be given with the greatest caution. In sHghter cases, particu- 
larly those in which the heart's action is impeded by deposits of 
fat, the endurance required for Oertel's terrain cure may be called 
upon. Sir William Stokes, as early as 1854, wrote of the neces- 
sity for such patients to "pursue a system of graduated muscu- 
lar exercises" for the symptoms of breathlessness. He states : 
"This treatment by muscular exercise is obviously more proper 
in younger persons that in those advanced in life. The symp- 
toms of debility of the heart are often removable by a regulated 
course of gymnastics or by pedestrian exercise, even in moun- 
tainous countries, such as Switzerland or the Highlands of Scot- 
land or Ireland." 

While the Swedes and the brothers Schott have since then 
emphasized the baths and the gymnastic side of this treatment, 
the pedestrian exercise was developed by Oertel into a sys- 
tem in which he combined walking and hill climbing with re- 
striction of fluids. To the treatment by exercise he added the 
drying out of the tissues. He made his patients walk on moun- 
tainous roads of different steepness for a period strictly regulated, 
gradually increasing the time and steepness of the road. It 
is a form of athletic training begiiming very cautiously and 
based on the principle that function makes structure, although 
in these pathologic conditions it must be kept strictly within the 
Hmits of resistance by the watchfulness of a physician. His 
system was founded on the result of treatment in his own case. 
He had kyphosis from a fall when a child, rickets, and a heredi- 
tary tendency to obesity, which became so marked when he was 
thirty years of age that the onset of dyspnea, cyanosis, edema of 
the legs, and a diminution of urine caused him to give up his 
practice. In 1875 he left for a mountainous district and spent 
there the month of August, where he first experimented with his 
ideas against the advice of his attendants, for at that time 
absolute rest was enjoined for such cases. The account of this 
first month is interesting. 

The first and second days he made short excursions in the 
morning and afternoon on level ground and climbed a hill 



500 



EXERCISE IN EDUCATION AND MEDICINE 



loo meters high. Breathlessness and palpitation made him 
stop after taking about twenty steps on level ground and after 
ten in going up hill, while the heat and effort made him perspire 
profusely. The third day he climbed a hill 157 meters high. 
When suffocation seemed inevitable, he rested and found relief 
in taking forced breathing while resting. This excursion lasted 
six hours and he lost much weight from perspiration, but that 
night he had neither irregularity nor palpitation. In the second 
week he could climb a hill 527 meters high, but it took him four 




Fig. 419. — Oertel's pulse tracing before beginning treatment (Lagrange). 

hours, twice the time for an ordinary person. He had to stop 
and rest 150 times. He had no evil effects that night. Owing to 
the profuse perspiration he had great thirst, which he reheved by 
gargling cold water, but he did not drink any more than usual. 

After four weeks he began to take longer excursions and found 
that he could endure them with comparative ease, and, although 
breathlessness came on more quickly than it should, the normal 
action of the heart was rapidly re-established by resting. 




Fig. 420. — Oertel's pulse tracing after si.x weeks' treatment (Lagrange). 

In six weeks' time he returned to Munich and again took up 
practice, having reduced his weight 8 kilos. His pulse remained 
normal in ordinary walking (Fig. 420), and he could go up two 
flights of stairs without breathlessness. This improvement was 
kept up by periods of training and rest for eighteen years, when 
Lagrange saw him and reported him in excellent health 



PLATE IV 




EXERCISE IN TREATMENT OF DISEASES OF CIRCULATION 50I 

Shortly after his return to Munich he estabHshed his cures. 
The one at Reichenhall is typical, and a map shows the details 
(Plate IV). The course was regulated with care and mi- 
nuteness. The paths were marked with stations, benches were 
placed for resting, and the trees beside the road had banks or 
flags of red, purple, green, or yellow, the colors representing the 
degree of its slant. The exercise was thus prescribed in de- 
grees of increasing distance and steepness. 

At the Battle Creek Sanatorium surveys have been made for 
a series of walks of increasing length and difficulty, and a formula 
given for calculating the amount of work done in foot pounds. 
This is given to the patient in pamphlet form, with hints about 
walking and cautions which greatly increase its value. Accord- 
ing to the Kellogg formula, walking at the rate of 3 miles an hour 
on a level road is equivalent to lifting the body one-twentieth of 
the distance, so that if we divide the distance in feet by 20, add 
to this the height of hills climbed, and multiply by the body 
weight, the result will be the work done in foot pounds. As 
the country about Battle Creek is comparatively level, the 
walks must make up in distance what they lack in elevation. 
The following is a typical walk: 



A 3 f -MILE WALK. 

Street. Distance. Elevation. 

Feet. Feet. 

Main entrance to Washington Ave 155 

On Washington from Sanatorium Ave. south to Van Buren. . 672 

On Van Buren and Hart east to Union 6,723 

On Union south to Marshall 2,577 6.5 

On Marshall west to Soldiers' Monument 3,55° 

On Main west to Washington 4,1,35 i5-2 

On Washington north to Sanatorium Ave 1,168 35.4 

To main entrance 155 8 



Totals 19.135 65.1 

iQ,i35 -^ 20 = Q56.7 

Equivalent number of feet body is lifted 1022 

Distance in rods 1 160 

Multiply 1022 by (body weight) = Amount of work done in foot 

pounds 



502 EXERCISE IN EDUCATION AND MEDICINE 

The range of the Oertel cure is strictly Hmited. It is, first 
of all, a preventive measure, and can be employed with advantage 
to improve the general nutrition and to prevent fatty infiltra- 
tion from becoming localized in the heart. Even m cases where 
this has already occurred it is still of great value, as it also is 
where the compensation has been already established by milder 
means. 

Where compensation is broken down, and where the patient 
is compelled to remam in bed, massage and the milder treatment 
by g3rmnastics, which are under more accurate control, have bet- 
ter results. They act more directly upon the peripheral circula- 
tion by unloadmg the engorged veins without undul}' overwork- 
mg the heart itself, and such a course may serve as a good 
preparation for the Oertel treatment where it would have been 
dangerous to begm with it. 

The application of massage and g}Tnnastics has been taught 
and employed since the time of Ling, but it has been most 
carefully studied and perfected by Auguste and Theodor Schott^ 
at Bad Nauheim. The treatment consists of regulated move- 
ments of the body, beginning at the extremities and employing 
the large muscle masses, combined with massage and the sys- 
tematic use of carbonated brine baths, such as are found at the 
Nauheim springs. The eft'ect of the baths is to stimulate and 
flush the skin, and so reduce the f requeue)- of the pulse and in- 
crease its force. They can be prepared artificially. 

The exercises are all duplicate movements, and each one 
must be slowly and evenly made, with a definite, firm eft'ort on 
the part of the patient. A short interval should be left between 
them to enjoin slow and regular breathing and to prevent the 
possibility of heart-strain. The patient should be constantly 
warned of the danger of holding his breath during the eft'ort, for 
by this act an undue and unnecessary strain is put on the heart 
walls already impaired by disease. The exercises should stop 
short of perspiration and palpitation, and the operator should 

^ Balneogymnastic Treatment of Chronic Diseases of the Heart, b>- Prof. 
Theodor Schott. 



EXERCISE IN TREATMENT OF DISEASES OF CIRCULATION 503 

be on the lookout for dilatation of the nostrils, drawing down 
of the corners of the mouth, duskiness or pallor of the cheeks 
and lips, yawning, sweating, or palpitation. 

The pulse should be frequently examined during treatment, 
and examination before and after treatment should show a 
constant reduction in the dulness over both the heart and the 
liver, accompanied by a sense of general rehef and freedom last- 
ing several hours. The pulse is increased m volume as its rate 
is reduced, and the breathing is made slower and deeper. The 
color of the lips and face is improved, and the size of the liver, 
when congested, is notably diminished. Marked diuresis usually 
follows after a few days' exercise. 

The movements cover in regular order, first, the muscles 
of the arms and forearms; then those of the trunk, thighs, and 
legs, exercising mildly every important group in the body by 
single contractions. 

While there are slight differences in the order as given by 
different practitioners, all unite in combining exercise with 
deep breathing; for example, in flexion of the knee the breath 
is slowly drawn in through the nose, and in extension it is 
expelled through the mouth. Each exercise is thus given 
slowly, at the rate of ordinary respiration, and is given once 
only, a minute's pause being allowed for rest. 

The following is the order of the exercises given by Bezly 
Thorne, in his book on the "Schott Methods of Treatment." 
For further instruction in the position of the operator's hands 
and other particulars, the reader is referred to the illustrations. 
All the movements are done with resistance from the patient. 
This resistance must be made very mild at the beginning of the 
treatment, the tendency being to employ too much force. As 
the patient shows capacity for enduring the fatigue the amount 
of resistance may be gradually increased, but treatment should, 
if anything, err on the side of safety, especially if any signs of 
distress are noticed. 




rig. 422. 

Figs. 421, 422. — Exercise I. Spread the arms (Fig. 421) until they are in line at the level 
of the shoulders. Bring them together (Fig. 422). 

504 




Fig. 424, 
Figs. 423, 424. — Exercise II. Fle.x tlie forearm (Fig. 423). Extend the forearm (Fig. 424). 

505 




Fig. 426. 

Figs. 425, 426. — Exercise III. Raise the arm sideways, palms upward (Fig. 425), until 

the thumbs touch above the head. Sideways lower (Fig. 42b). 

506 




Fig. 428. 
Figs. 427, 428. — Exercise IV. Press together the knuckles of both hands with the 
fingers flexed at the second joint. Raise the arms (Fig. 427) above the head. Lower the 
arms (Fig. 428) to the starting-point, in front of the abdomen. 

507 




Fig. 430. 

Figs. 429, 430. — Exercise V. Arms forward raise (Fig. 429) until vertically above the 

liead. Forward lower (Fig. 430). 

508 




Fig. 431- 




Fig. 432. 
Figs. 431, 432. — Exercise VI. Forward flexion of the trunk (Fig. 431). Extension (Fig. 432). 

509 





Fig- 434- 
Figs. 433, 434. — Exercise VII. Trunk 
rotation. The operator must change his 
position from Fig. 433 to Fig. 434, as the 
patient turns, keeping up even resistance 
throughout the entire movement, and pass- 
ing partially around him. 



Fig. ^5.— Exercise VIII. 

Flex the trunk to the right and to 
the left alternately. Straighten. 



510 



Exercise I X. — This move- 
ment is identical with Exercise II 
(Figs. 423, 424), except that the 
fists are clenched. 



Exercise X. — This movement 
is the same as Exercise IX, ex- 
cept that the arm is at the side. 






% 



/ 





Fig. 436. — Exercise XI. Rotate the 
arm forward, upward, backward, and 
downward. 



Fig. 437. — Exercise XII. Push both arms 
backward; draw them forward. 



511 




Fig. 43S. 




Fig. 439- 
Figs. 43S, 439. — Exercise XIII. Flex the thigh, with knee bent (Fig. 438). Relax. Ex- 
tend the thigh (Fig. 439). 

- 512 




Fig. 440. 




Fig. 441. 

Figs. 440, 441. — Exercise XIV. Extend the leg and bring the straight leg forward (Fig. 

440). Draw the leg backward (Fig. 441). 

33 513 




Fig. 44-"- 




Fi?. 443- 
Figs. 442, 443. — Exercise XV. Flex the leg and thigh (Fig. 442). Extend the leg (Fig. 443)- 

514 




Fig. 444. — Exercise XVI. Abduct the leg. Adduct the leg. 

Exercise XVII. — Arms extended horizontally. Rotate for- 
ward and backward with resistance. 




Fig. 445. — Exercise XVIII. Extend the hand. Flex the hand. 
515 




Fig. 446. — Exercise XIX. Flex the foot. Extend the foot. 

This completes the full set of exercises. Each exercise is 
done once only and given very slowly. The resistance is strong, 
but the movement must not be jerky. A minute's pause is 




EXERCISE IN TREATMENT OF DISEASES OE CIRCULATION 517 

allowed after each exercise and the pulse is taken after every 
three exercises. The resistance should be increased only as the 
patient shows the capacity to endure it. The rate should be 
slow and uniform, and abundant rest given until the indi- 
vidual's Hmitations have been gauged. Most of them may be 
done in bed if necessary. 

Some form of artificial respiration may be profitably added 
to any treatment of these conditions, either in the forms already 
described or in the chest-raising or shoulder-raising (Fig. 447) 
described by Satterthwaite,^ in which the patient inhales as 
the operator lifts and exhales as the operator relaxes. This 
is repeated eight to sixteen times, with one or two natural 
respirations between each movement. Satterthwaite has fur- 
ther modified the technic of the Schott treatment by arrang- 
ing the exercises in series of progressing difficulty, all of which 
include massage of the thigh and back. 

The following is a brief outline of the course of exercise 
carried on for the first two weeks: 

Scheme No. I 

1. Chest lifting, lying or sitting 2 minutes. 

Intermission i minute. 

2. Foot and leg massage 2 minutes. 

Intermission i minute. 

3. Forearm flexion and extension i " 

Intermission i " 

4. Hand and forearm massage 2 minutes. 

Intermission ■• i minute. 

5. Leg and thigh flexion and extension 2 minutes. 

Intermission i minute. 

6. Arm and shoulder massage 2 minutes. 

Intermission i minute. 

7. Thigh flexion and extension 2 minutes. 

Intermission i minute. 

8. Chest percussion 2 minutes. 

Intermission i minute. 

9. Trunk flexion and extension 2 minutes. 

Intermission i minute. 

10. Thigh and back massage 2 minutes. 

Total length of seance .28 minutes. 

1 Thomas E. Satterthwaite, Diseases of the Heart and Aorta. 



5l8 EXERCISE IN EDUCATION AND MEDICINE 

This is increased in severity and the order sUghtly changed 
in Scheme II, which is carried on for the third and fourth weeks: 

Scheme No. II 

1. Chest lifting, lying or sitting 2 minutes. 

Intermission i minute. 

2. Foot and leg massage 2 minutes. 

Intermission i minute. 

3. Forearm flexion and extension 2 minutes. 

Intermission i minute. " 

4. Hand and forearm massage 2 minutes. 

Intermission i minute. 

5. Leg abduction and adduction 3 minutes. 

Intermission i minute. 

6. Arm and shoulder massage 2 minutes. 

Intermission i minute. 

7. Trunk rotation 3 minutes. 

Intermission i minute. 

8. Chest percussion 2 minutes. 

Intermission i minute. 

9. Arm separation 3 minutes. 

Intermission i minute. 

10. Thigh and back massage 3 minutes. 

Total duration of seance ^^ minutes. 

Scheme No. Ill 

1. Chest lifting 2 minutes. 

Intermission , i minute. 

2. Foot and leg massage 2 minutes. 

Intermission i minute. 

3. Quarter circling (forward and backward) 4 minutes. 

Intermission i minute. 

4. Hand and forearm massage 2 minutes. 

Intermission i minute. 

5. Head rotation or flexion 3 minutes. 

Intermission i minute. 

6. Arm and shoulder massage 2 minutes. 

Intermission •. . . i minute. 

7. Trunk twisting 4 minutes. 

Intermission i minute. 

. 8. Chest percussion 2 minutes. 

Intermission i minute. 

9. Trunk flexion (lateral^) 4 minutes. 

Intermission i minute. 

10. Thigh and back massage 3 minutes. 

Total duration of seance 37 minutes. 



EXERCISE IN TREATMENT OF DISEASES OF CIRCULATION 519 

For the fifth and sixth weeks a further change in the series is 
made, and some new exercises are introduced that might not be 
well borne at the beginning of the course, particularly quarter 
circling and head rotation. 

It will be noticed that in this final series the exercises involve 
newer and larger groups of muscles, and that all the great muscles 
of the body have been exercised. The duration of the seance is 
also longer, and more force should be applied. The movements 
should be very slow, and the intermission should be carefully 
observed, the fault of the operator being usually in shortening the 
intermission, increasing the amount, and using undue force. 
The patient should also be urged to breathe freely and naturally, 
and the operator should be on the lookout for irregular breath- 
ing, pallor, blueness of the Hps or face, or any sign of personal 
discomfort or disturbance on the part of the patient. Upon the 
appearance of any of these signs exercise must be suspended, 
since they indicg-te that there has been undue resistance or that 
the movement has been too rapid or the intervals of rest cur- 
tailed. Heineman, of Nauheim, was strongly of the opinion 
that no exercise should be used in which the hands are brought 
above the level of the shoulders, on account of the increased 
work required of the heart in raising the column of blood to this 
unaccustomed height. With this opinion Satterthwaite agrees. 

The exercise treatment is unusually successful in conditions 
of heart weakness complicated by obesity, where improvement 
should be noted from the first. It is of undoubted value in most 
valvular disease, with signs of failing compensation, the dilata- 
tion of the peripheral vessels resulting from the exercises being 
followed by an improvement in the strength of the pulse and a 
lowering of the rate, an improvement that may be maintained 
for years. In most cases the patients may return to their ordinary 
occupations and duties, and if signs of relapse begin to appear, the 
taking of a course is sufficient to re-estabUsh the equilibrium until 
the heart shares in the inevitable degeneration of advancing age. 



CHAPTER XXIX 

OBESITY: ITS CAUSES AND TREATMENT 

The excessive accumulation of fat must be considered as a 
s>inptom rather than as a disease. It is due to overnutrition, to 
underoxidation, or to a combination of both acting together. 

When the allurements of the table are too great for the 
body's needs, the surplus is stored up as fat in the tissues least 
disturbed by muscular action, like the omentum and mesentery, 
and local deposits are made in the region of the abdomen and 
hips or in a general layer throughout the subcutaneous tissue 
of the entire body. 

Heredity has a marked influence in this fat-making tendency, 
about 60 per cent, of cases reported by Anders having this history, 
while its association with gout, that other disorder of overfeed- 
ing and underexercising, was found in 43 per cent, of his cases. ^ 

The normal oxidation of the ingested food may be hindered 
by a sedentary life involving little tissue waste from muscular 
exercise, or by the mental and physical torpor and habitual 
inactivity of the too ardent pupils of Silenus, whose fat is also 
protected from combustion by the rapidly oxidizing alcohol, 
which retards all tissue waste and so favors increase in bulk. 
It may also be hindered by lack of the proper functioning 
of the thyroid gland. 

Fat is a cheaper form of tissue than muscle, requiring as it 
does a less abundant blood-supply, and its presence should be 
considered as an evidence of lowered nutrition. 

As the amount of fat increases the desire for exercise dimin- 
ishes, and the capacity for activity is lessened because of the 
speedy exhaustion that follows any unusual muscular work. 

1 See System of Medicine, Osier and McCrae, vol. i, 846. 
520 



obesity: its causes and treatment 523 

the size of the thyroid gland noted, and a series of physical 
measurements taken, including the weight and girths. 

In all diseases that impose increased work on the heart, 
like arteriosclerosis or emphysema, there is hypertrophy, with 
danger of dilatation and insufficiency, especially when the body 
is encumbered by excessive fat. The reduction of this fat con- 
stitutes one of the most valuable means in the treatment of most 
circulatory diseases, unless they are so far advanced as to render 
restoration of the heart to its functional activity impossible. 
Cases in which sKght disorders of the circulatory apparatus are 
present give the most satisfactory results, while, even in ad- 
vanced cases, improvement can be obtained by beginning gradu- 
ally and watching the heart condition carefully. When com- 
plicated by diseases of the kidneys, like atrophic nephritis, 
obesity is a real menace, and the reduction is not contra-indi- 
cated, but advised (Von Noorden). 

Chronic bronchitis is a frequent complication of obesity, and 
the removal of superfluous fat will enable the patient to breathe 
more deeply, encouraging a free circulation of blood through the 
lungs, so that such cases sometimes heal under this treatment 
alone. 

Chronic articular rheumatism favors obesity by preventing 
the patient from moving freely, particularly if the regions of the 
legs or pelvis are affected. Anders found it in 35.5 per cent, of 
his cases. The same may be said of gout, the reduction treat- 
ment of which, through diet and exercise, is of the first import- 
ance. Most gouty middle-aged men present a history of violent 
indulgence in physical exercise during youth, followed by a 
luxurious and inactive later life, with overfeeding and excessive 
indulgence in alcoholic liquors. 

In diabetes a reduction cure should never be undertaken, 
especially if the obesity be only shght or moderate, although in 
cases where it is excessive, accompanied by heart symptoms, the 
patient should, where possible, be reheved of any excessive fat. 
Only in this way can the heart be protected from excessive strain, 
but it should be used with the greatest caution. 



524 EXERCISE IN EDUCATION AND MEDICINE 

In selecting cases for the reduction cure three considerations 
should be held in mind: first, the amount of inconvenience the 
obesity causes; second, the presence and extent of the complica- 
tions referred to above; and third, the age and general nutrition 
of the patient. 

When obesity is moderate or extreme the physician may be 
consulted from vanity, which may thus become one of the most 
powerful levers in his hands to insure the thorough and com- 
plete carrying out of the irksome rules that the patient must 
follow if the desired result is to be obtained. This seemingly 
trivial consideration is one on which the success of the treatment 
often hinges in the ease-loving, luxurious class from which so 
many of these patients come. In young and sound adults active 
courses of five weeks or more may be repeatedly undertaken 
with safety, allowing intervals during which the loss of weight 
is merely maintained. In those of advancing age, where the 
obesity is extreme and the vital energies are beginning to fail, a 
reduction cure would only accelerate decay and lead to rapid 
loss in strength and functional power, with the continual added 
risk of heart failure. 

Reduction cures may be divided into three classes or degrees 
of rapidity: 

1. The first degree, in which the loss is very slow, the patient 
losing 2 or 3 pounds a month. It applies to those with an 
enviable amount of fat which shows a tendency to increase. It 
does not require great sacrifice from the patient, who must 
alter her diet by the reduction of fat, starchy, and sweet foods, 
restrict or abandon alcohoHc beverages, take only foods of small 
caloric value, and engage in regular active physical exercise. 

2. The second degree, in which loss should be from 5 to 10 
pounds a month, applies to strong, plethoric subjects, who can 
safely indulge in active exercise. The diet is more strict, and the 
exercise more varied. It is especially valuable for individuals in 
whom complicating disorders of the heart, arteries, bronchi, or 
digestive apparatus render it impossible to take from the start 
the more rapid or — 



obesity: its causes and treatment 525 

3. The third degree of the reduction cure, which should be 
carefully supervised and may be carried out at an institution 
with advantage. As much as 30 pounds a month can be lost 
with safety, but five or six weeks is the longest time during 
which it should be put in force. In most cases it will be neces- 
sary to carry it on for four to six weeks and then have a month 
or two of less strenuous exercise and regimen, repeating the 
course thus intermittently until the desired loss of flesh has been 
attained. 

The reduction treatment falls under the three heads of diet, 
exercise, and drug therapy. 

In diet the caloric requirements are reduced to four-fifths of 
the normal in the first course described, in the second to three- 
fifths, and in the third to two-fifths. This is obtained by sub- 
stituting for more nourishing food such articles as bouillon, coffee, 
or fruits, which have small caloric value. Lean meats should be 
given preference. Cheese often serves a useful purpose, partic- 
ularly in small quantities, as it is very filling. Milk is a useful 
addition to the bill of fare, buttermilk being still more useful. 
Among vegetables, those varieties that grow under ground, as 
well as those that grow in a pod, should be restricted, because 
they contain a large amount of carbohydrates. All the other 
vegetables are exceedingly useful articles of diet if they possess 
small caloric value in proportion to their bulk, and consequently 
fill the stomach rapidly, producing a sense of satiety. They also 
act favorably on the function of the bowels. Fruits of all kinds, 
with the exception of bananas, sweet grapes, figs, dates, and 
raisins, are permitted without reserve, as they have a low caloric 
value, are filling, and act well upon the digestive apparatus. 
Bread is satisfying to the eye without possessing great caloric value. 

The intake of liquids must be strictly limited. The weight 
of an obese subject is rapidly reduced by restricting the liquids 
to a minimum. This loss of weight is apparent during the 
first four or five days of a cure, being due to a direct loss of 
water from the tissues by the air-passages, skin, and kidneys, 
and to the fact that one is incHned to eat less when not drinking 



526 EXERCISE IN EDUCATION AND MEDICINE 

freely. This rapid initial loss is of great value to the physician 
in giving a patient confidence in the method employed. She is 
put in the right frame of mind to persevere in carrying out the 
distasteful but stringent rules that must be enforced. 

Boxers and jockeys who have to reduce their weight rapidly 
to a set figure, much below their normal, accomplish it by pro- 
fuse sweating and abstaining from liquids. When excessive 
this is most exhausting to the system, and in making matches or 
contests it is frequently stipulated that the man be weighed 
six or eight hours before a fight, so that this abnormal loss of 
weight may be regained in part and the strength restored by 
eating and drinking copiously of fluids before the beginning of 
the contest. From 5 to 10 pounds may thus be gained in a few 
hours. Losses of weight up to 14 pounds in one and one-half 
hours have been reported during football games in men at the 
beginning of training by Professor A. A. Stagg of Chicago Uni- 
versity and Dr. James Naismith of the University of Kansas, 
entirely and rapidly regained after eating and drinking. 

The patient's general mode of life must be regulated, always 
a difficult feat to accomplish. Habits of ease and indolence 
should be replaced by greater general activity, and interest in 
outdoor games, like golf and walking excursions, should be 
created to impel her to take a large amount of general exercise. 
Not many patients have either the courage or perseverance 
to voluntarily undertake and persist in such a course of diet 
as that described by Sam G. Blythe in his interesting book, 
"The Fun of Getting Thin." 

The influence of hiassage is very problematic, according to 
Von Noorden's experiment, referred to in Chapter XIX. He 
believes that the effect is more on the metaboKsm of the masseur 
than on that of the patient. 

All the methods of treating obesity rest on the double 
rule of diminishing food and increasing elimination. Dr. Ber- 
gonie, professor of biologic physics and medical electricity at 
the Bordeaux medical school, obtains artificially intense muscular 
activity by causing an alternating electric current of 8 to 12 



obesity: its causes and treatment 527 

volts and of an intensity of 50 milliamperes to pass through the 
body of the patient with a frequency of 40 to 100 per second. 
The patient rechnes over a large electrode, the other electrode 
covering the greater portion of the anterior surface of the body. 
Under the influence of the current all the important muscular 
masses (thighs, calves, buttocks, back, shoulders) are animated 
with muscular contractions sufficiently energetic to elevate the 
body, even when weighted down at the level of the thighs by 
a weight of 88 pounds (40 kilos) or more. 

According to Dr. Bergonie's recent communication to the 
Academy of Sciences {Academie des sciences), and to the French 
Association for the Advancement of Sciences {Association 
francaise pour Vavancement des sciences), this treatment will 
cause a very rapid diminution of the weight of fat, if the patient 
is careful to maintain his diet at a ratio inferior to that which 
corresponds to his muscular outlay; it will, moreover, increase 
strength and resistance to fatigue. Kellogg obtains the same 
result by the sinusoidal current, which is less painful. It is, 
however, to the more active forms of exercise we must go for 
the best results. 

When the accumulation of fat is unevenly distributed, a 
daily prescription of ten exercises should be given, to include 
the entire muscular system, but with emphasis on the regions 
where the deposit is thickest, for fat tends to accumulate in the 
subcutaneous tissue covering the groups that are dormant, like 
the abdominals or muscles of the neck. Such exercises have been 
shown in Figs. 255, 390, 392, 394, 401, 406, 407; Plate II, Fig. 
2; Plate III, Figs, i, 2. 

When the omentum, mesentery, and abdominal walls are 
excessively overburdened, the exercises shown in Plate II, Fig. 
2, and Figs. 392 and 394 are of special value. To these maybe 
added the three following, and selection of about ten in all made 
to suit the special case : 

Exercise I. — Patient lying supine, arms above the head, grasp- 
ing a support. Raise both feet 12 inches without bending 
the knees. Alternately raise and lower the feet (Fig. 450) ten 



528 



EXERCISE IN EDUCATION AND MEDICINE 



times without touching the table. The extent of the raising and 
lowering should not be more than 12 inches. 

This brings the abdominal muscles into action, and should be 
repeated with rests up to thirty minutes. 




Fig. 450. 

Exercise II. — Patient lying supine, hands on the hips. 
Raise the head and shoulders until the feet can be seen. Twist 
to the right, to the left, and slowly return to the starting posi- 
tion (Fig. 451). This may be used as an introductory exercise 
to the next, in which the same muscles are employed with 
greater visor. 




Fig. 451. 

Exercise 7/7.— Patient lying supine with the feet fixed and 

. hands clasped behind the head. Raise the body to the upright 

position, and slowly lower to the starting-point (Fig. 452). This 

may be accentuated by having the trunk overextended, as in 

Fig. 451, which is a form of the same exercise rendered more 



obesity: its causes and treatment 529 

difficult by having the arms behind the head as shown in the 
position of Fig. 394. 

A prescription should begin with the lightest exercise, and the 
dosage should be increased rapidly in length and severity accord- 
ing to the muscular strength and the condition of the pulse. 

After each of the first two or three treatments massage is of 
distinct value in relieving the muscular soreness, but it seems to 
have no direct effect in reducing the weight. 

Accompanying this gymnastic treatment, regulated walking, 
at first on level ground and then up an increasingly steep in- 
cline, is of the utmost value, beginning with a climb sufficient to 
produce moderate breathlessness, and increasing the length and 




Fig. 452. 

steepness as the patient's ability improves. Von Noorden 
calculates that an individual of 100 kg. climbing to an elevation 
of 1000 m. consumes at least 700 calories. This is the Oertel 
"terrain cure," as described fully in the previous chapter. 

The elimination of fluids may be increased by the use of such 
aperient waters as those of Kissingen or Vichy, which are used on 
alternate days, one glass every morning before breakfast or at night. 

The principal medicinal agent employed in reduction cures is 
extract of thyroid gland, given in doses up to 5 grains three times 
a day in thyrogenous cases, and stopped promptly if any sign of 
heart distress or weakness appears. 

A daily treatment, such as outlined above, accompanied by 
34 



530 EXERCISE IN EDUCATION AND MEDICINE 

proper regulation of the diet, should steadily and consistently bring 
down the weight in moderate and even extreme cases of obesity. 

In one of my patients, a young lady aged twenty, it was 
reduced by these means from 208 pounds to 167 pounds in a 
period of four months, which included several weeks lost by 
interruptions. By a very much modified home prescription 
this improvement was maintained at the last examination, taken 
six months afterward. 

The most remarkable case of reduction reported is that of 
George Cheyne, born in Scotland in 167 1. By the time he was 
thirty his excesses in eating and drinking had brought his weight 
up to more than thirty-two stone (448 pounds), and made him 
very short breathed, lethargic, and listless. He dieted on milk 
and vegetables, exercised freely, and so reduced himself to almost 
one-third (150 pounds). He recovered his strength and lived to 
the age of seventy- two, writing an essay on health and long life. 

During a reduction cure the heart should be carefully ex- 
amined from time to time, and the work decreased if signs of 
palpitation or edema of the extremities are found. Otherwise 
the heart may be injured, and such a dilatation is apt to remain 
where there is but a small reserve of power on which to draw. 
It may be necessary to discontinue the exercises entirely or 
reduce them to slow-breathing movements alone. 

An obese individual who attempts to reduce weight merely 
by undernutrition always incurs the danger of sacrificing body 
albumen and of reducing the strength of the whole body. This 
is avoided if muscular exercise is included in the course (von 
Noorden). Sometimes, when loss of weight is rapid and ob- 
tained by means of drugs and diet alone, without care to im- 
prove the muscle tone and so to support the viscera, certain 
complications arise (constipation, hernia, and gastroptosis) , 
particularly in middle-aged and flabby women. Displacement 
of the kidneys and uterus may also be traced to the rapid ab- 
sorption of the surrounding fat, and symptoms caused by 
such ptoses have in rare cases been found to be more trouble- 
some than the obesity itself. 



CHAPTER XXX 

EXERQSE IN THE TREATMENT OF NERVE PAIN 
AND EXHAUSTION 

Massage, vibration, and active exercise have a large place 
in the treatment of disorders of the nervous system as exhibited 
by pain or exhaustion, both local and general; by perversion of 
movements and function, or by actual destruction of the con- 
ducting mechanism for motion and sensation. By these means 
pain may frequently be controlled, jangling nerves attuned, 
exhaustion reheved, vagrant nervous manifestations brought 
back into their proper paths, and damaged or lost co-ordinations 
re-estabhshed. 

Headache. — In myalgic headache the treatment is pre- 
eminently massage, which must begin by the gentlest form of 
effleurage. The points of induration having been made out and 
the painful areas outlined,^ the treatment should begin by strok- 
ings with the thumbs or finger-tips, starting from the supra- 
orbital ridge upward and outward ; the infra-orbital and mental 
nerves should be treated in like manner, also the occipitals. Such 
a treatment will last for four or five minutes, and may be varied 
by using the flat of the hand in slow circular frictions as tolerance 
is established. The temporal artery, which is hard and cord-Uke 
under the finger, will be found to relax slowly and the cold 
and bloodless area of its supply becomes suffused and soft. 

Vibration can here be of value if the Kght brush applicator 
is used centrifugally along the course of the affected nerves, 
and care taken not to use too much force. The time should 
be only a few seconds, followed by a pause, and the entire treat- 
ment should not last more than two or three minutes at the 
most. The congestion may well be diverted by deep kneading 

^ White and Jelliflfe, page 149. 

531 



532 EXERCISE IN EDUCATION AND MEDICINE 

of the muscle masses of the neck, throat, and shoulders. Many- 
congestive headaches are accompanied by stiffness of these 
muscles, amounting in some cases to spasm, and slow, deep, and 
insistent kneading, with frictions along the course of the inter- 
nal jugular veins, re-establishes the normal circulation and 
relieves the nervous tension. Drugs can reach such conditions 
but indirectly or not at all, and osteopathy and other manual 
cults fatten on these cases so often neglected by the average 
physician. 1 

Neuralgia.-^In true neuralgia massage is of more value be- 
tween the paroxysms, tending to lengthen the intervals (Graham) 
and lessen their severity, but one must not expect great results in a 




Fig. 453. — Kneading and friction along the jugular veins to relieve congestion in the head. 

condition which may depend on disturbances of the bony canals 
through which the nerves pass, or on such conditions as decayed 
teeth. The cause must be treated. The best manipulation is 
light efifleurage, followed by gently kneading with the warm open 
hand. Firm pressure on the painful point at the exit of a nerve 
instead of aggravating it frequently. benumbs it. 

Vibration has taken an important place in the treatment of 
neuralgia since the experiments of J. Mortimer Granville. Acute 
sharp pain he likened to a high note in music produced by rapid 
vibrations, while a dull heavy or aching pain he likened to a 
low note produced by slow vibrations. A slow rate of mechan- 
ical vibration upon the nerve interrupts the rapid vibrations 

1 Jelliffe, Modern Treatment of Nervous and Mental Diseases. 



THE TREATMENT OF NERVE PAIN AND EXHAUSTION 533 



of acute pain, while quick vibration arrests the slower ones of 
dull pain. He attempted to bring discord into the rhythm of 
morbid vibrations, and so reHeve or cure the neuralgia by 
his instrument, the "percutor," in which the rate of blows could 
be changed at will. This was the forerunner of the modern 
vibrators. 

Neuritis. — Vibration over 
the lower lumbar and sacral 
regions for inflammation of the 
sciatic nerve is frequently fol- 
lowed by immediate relaxation 
of the pain and muscular 
spasm. 

In sciatic neuritis this treat- 
ment has been used with great 
success, either in the form of 
vibrations, as described above, 
or after the method of A. 
Symonds Eccles,^ who starts 
with two daily treatments of 
five or ten minutes after the 
first few days of the disease, 
gradually increasing them to 
twenty minutes each. He uses 
friction and kneading directly 
along the course of the nerve 
and its branches, beginning at the heel and working upward. 

Before giving a prognosis or undertaking treatment the diag- 
nosis between neuritis and .rheumatism should be made. 

Muscular rheumatism is aggravated by motion and relieved 
by rest and warmth, whereas in a true neuritis the pain is worse 
at night, while the patient is warm and at rest, and wears off 
when he is up and moving about. 

The relief from discomfort and the freedom of motion ex- 
perienced after each massage is great, although but temporary, 
^ The Practice of Massage. 




Fig. 454. — Stretching the sciatic nerve. 



534 



EXERCISE IN EDUCATION AND MEDICINE 



and repeated massage, extending throughout the necessarily 
slow recovery, increases materially the patient's comfort. In 
the later stages, when the pain is almost gone and stimulation is 
well borne, hacking movements and deep vibration across the 
nerve are added. Passive movements in which the thigh is 
flexed, the knee-joint being kept in extension, stretch the nerve 
and frequently give rehef (Fig. 454) ; and, finally, toward the end 
of the treatment, active movements are of value in counteracting 
the atrophy that results from inaction and thfe disease itself. 

Graham deprecates the use of massage over the sciatic 
nerve, and confines his manipulations to the muscle masses of 
the front and sides of the thigh, with gentle strokmg only on the 
posterior aspect of the limb. Where hacking and percussion are 
used the movements should be gentle, and any increase in the 
pain after massage should be a sign to desist. 

Massage is not well borne in brachial neuritis, especially 
during the acuteness of the attack, and absolute rest is then 
essential. Only in the later stages may it be employed, and then 
with precautions to avoid a re-awakening of the inflammatory 
process. 

Rheumatism. — In muscular rheumatism or myositis massage 
causes absorption of the exudate. The hard nodules that can be 
made out in the lumbar fascia and muscles disappear, pressure 
on the nerve filaments is reUeved, and minute adhesions are 
broken down. The relief is frequently instantaneous in acute 
cases, and in chronic the progress is steady toward cure, unless 
the treatment be made too severe and the tissues unduly irri- 
tated or bruised. 

Occupation Palsies.— Among the most easily awakened and 
persistent pains due to the interference with the nerve is that due 
to exhaustion, caused by the persistent overwork of one group of 
muscles, known collectively as occupation neuroses. 

Scriveners' palsy has become comparatively rare with the 
increased use of the typewriter, but exhaustion neuroses are 
frequent among piano-players and violinists, baseball pitchers, 
and telegraph operators. 



THE TREATMENT OF NERVE PAIN AND EXHAUSTION S3 5 

While no morbid anatomic change can be made out, this 
trouble appears to be the result of an exhaustion or overexcita- 
bility of the centers controlling the muscular movements most 
involved. The symptoms are cramps and spasms of the muscles, 
weakness and debility, extending even to paralysis, tremors, a 
feeling of great tiredness, with acute shooting pains, and some- 
times a subacute neuritis with pain, numbness, or tingling in the 
fingers. These conditions run at best a chronic course, which 
can be greatly shortened if perfect rest from the habitual move- 
ment and daily massage and manipulation with simple gym- 
nastics be applied. Lauel also recommends superheated air. 
One of my cases, a violinist, a nervous girl of fourteen, had 
fatigue pains coming on rapidly and numbness of the third and 
fourth fingers of the left hand. A daily course of friction and 
kneading of the fingers and small muscles of the hand, forearm, 
arm, and shoulder, accompanied by manipulation of the joints 
separately with a few simple gymnastic exercises for the fingers 
separately and together, brought about a complete recovery in 
about two months, enabling her to resume her study. This is an 
unusually favorable result, and under the best of conditions the 
tendency to relapse must be kept in mind. 

In another of my cases, a student, the weakness and pain was 
confined to the flexor surface of the thumb and first finger and 
the flexor surface of the forearm, with occasional tremors; 
after writing for ten minutes the pen would drop from his hand. 
These symptoms came on again after a five months' rest, in 
which no writing was done. His hand was cold and weak, and 
he was quite unable to go on with his college course. Daily 
treatment with massage of the hand and forearm enabled him 
to finish the five months necessary to complete his session, but 
the danger of relapse was always imminent if he undertook any 
unusual task. 

Much trouble could be prevented by avoiding the cramped 
style of writing that keeps the muscles of the thumb and fingers 
in continuous contraction. An attempt has been made to do 
this by J. Liberty Tadd, who teaches drawing by great free-arm 



536 EXERCISE IN EDUCATION AND MEDICINE 

movements, using either or both hands at the blackboard, and 
also by the Palmer method of writing for school children, which 
is designed to enable the pupil to write a clear, legible, and grace- 
ful hand, while at the same time he gains the commercial rate of 
speed. 

This method of writing brings the entire arm into play. 
The hand is not allowed to rest on the paper. While the strength 
of the fingers alone moves the pen, several additional sets of 
muscles are brought into action. The physical effort of writing 
is thus distributed among several groups and the local fatigue is 
greatly reduced. A much freer swing is imparted to the hand 
and a greater speed may be obtained. The commercial writer, 
the clerk who has worked for years, often falls unconsciously 
into this method, which he finds will enable him to write faster 
and with less effort than others. The pupil who is trained by 
such a method from the beginning therefore learns what the 
skilful clerk has taught himself as the result of years of experi- 
ment. 

The whole arm is used in writing instead, as is often the case, 
merely the finger muscles. The movement of the muscles of the 
fingers is extended as far as the shoulder. The fulcrum should be 
below the elbow. The movement of the arm is, therefore, com- 
paratively slight ; the forearm moves back and forth like a piston, 
with short, rapid strokes. If the movement be directed from the 
upper arm and the shoulder, the effort is unnecessarily increased. 
This system also makes it possible to sit erect, with the body 
free from strain. 

The regularity of movement is as carefully watched as in 
music. A jerky, spasmodic motion may be found reflected in 
the letters. Many teachers use some regular method of mark- 
ing the time of making parts of letters. In some cases a metro- 
nome or musical instrument is employed, while others merely 
beat time with a ruler and a chalk box. 

Neurasthenia. — The exhaustion of a single group produces a 
local effect only, but with a general exhaustion we find the long 
train of constitutional S3rmptoms that may be grouped under the 



THE TREATMENT OF NERVE PAIN AND EXHAUSTION 537 

heading of neurasthenia, or general exhaustion of the nervous 
system with its distressing train of pains and perversions of 
nerve function. 

The discovery of the "rest treatment" by Weir Mitchell in 
1874, and its development in America and abroad following 
publication and translation into seven languages of his book 
"Fat and Blood" in 1897, attracted attention to rest and mas- 
sage for these conditions. Rest could not be given without 
providing means for the assimilation of the increased amount of 
food given in his system of overfeeding. Elimination of waste 
would not take place unless stimulated by artificial means to 
meet the artificial conditions under which the patient was 
placed, so that hysteria or neurasthenia require massage and 
resistive movements for their complete management. 

In Weir Mitchell's treatment for these disorders he first 
counteracts the evil effects on the digestion of overfeeding and 
continual rest in bed by massage and gymnastic movements, to 
reaccustom the patient gradually to the muscular tasks of daily 
life.i 

His custom was to begin with a general massage after the first 
few days of milk diet, the hour chosen being midway between 
two meals, the patient remaining in bed. The operator starts 
with the feet, continues the manipulations up each leg, then to 
the muscles of the loins, spine, abdomen, and chest. The order 
of movements is described in the chapter on Massage. The 
entire treatment lasts about one-half hour, and is gradually in- 
creased up to one hour, followed by one hour of rest. This is 
continued for at least six weeks, and then one-half hour is de- 
voted to massage, and the other one-half to movements of 
flexion and extension of the limbs and trunk with resistance. 
In the less severe cases confidence is put in the more active 
forms of exercise. One young man referred to me by him began 
by wrestling exercises, in which at first he did Httle more than 
gently resist the various positions, locks, and throws. The 
resistance gradually increased in force and duration until, at the 

^S. Weir Mitchell, Jour. Am. Med. Assoc, June, 1908. 



538 EXERCISE IN EDUCATION AND MEDICINE 

end of three months, he had gained 16 pounds m weight, and 
had improved so much in strength, courage, and vigor that he 
was sent home cured. Other cases derive the greatest benefit 
from an active outdoor Hfe, in which camping, swimming, walk- 
ing, riding, and wrestluig form a great part of the day's program. 
Exercise should be made as simple and interesting as pos- 
sible, the object being to improve the nutrition to the utmost 
without unduly exhausting the attention or overtaxing the co- 
ordination. For this reason, exercise demanding skill and' con- 
centration Hke fencing should be avoided. 



CHAPTER XXXI 

TIC, STAMMERING, AND CHOREA 

There are certain functional disturbances of the nervous 
system that show themselves in spasmodic habit movements 
of the face and body Uke blinking and torticollis, in disordered 
co-ordination of speech like stammering and stuttering, and in 
choreiform movements of the body. 

They may be classified under the general term tic, and are 
all psychoneuroses, often varying directly with fatigue and 
partly restrained by the will. They are physiologic acts that 
have become meaningless through inco-ordination and pernicious 
habit. The treatment must be the re-education of co-ordinate 
movements and the training of the patient to break up the 
harmful neuromuscular custom. 

The inhibition gymnastics of Oppenheim lay great stress on 
training the patient to voluntarily inhibit a reflex. A pointed 
instrument is approached to the eye of a blinking patient, who is 
admonished not to blink. The patient is touched and instructed 
not to start away as formerly. The exercises aim to train the 
will and control. In his exercises Brissand strives to replace 
abnormal by normal movements, and especially to train the 
patient in immobility where they have an uncontrollable desire 
to move, just as does Oppenheim. He gives them treatments 
three times a day, each one short enough to avoid fatigue and to 
maintain the interest of the patient. In these exercises the an- 
tagonistic movements should be used; for example, drawing 
the mouth to the left where the habit is to twitch it to the right. 
Slow, deep breathing with the back to the wall, arms raising and 
lowering as in Figs. 406, 407, Pitres' method, makes a good in- 
troduction to a treatment, while sports and games demand- 
ing attention, skill, and accuracy (p. 79) are of marked value. 

539 



540 EXERCISE IN EDUCATION AND MEDICINE 

Under treatment the prognosis is good, except in defective sub- 
jects. 

Certain special forms of tic require special treatment. Charles 
K. Mills^ treats aphasia in a purely pedagogic way by repetition 
of letters, words, phrases, and sentences, recognized by the 
patient in reading or after seeing or touching. 

Cramps and hypertonicity of the breathing muscles, of the 
laryngeal muscles, and of those of the palate, tongue, and lips 
used in articulation, must be treated in somewhat the same 
way. In E. W. Scripture's melody cure he begins to teach 
the patient to speak melodiously, using little verses and slid- 
ing the voice somewhat excessively. Then he is taught to 
speak and converse with melody, to break up his old habits of 
speaking. He makes great use of gestures to distract the mind 
from the vocal apparatus and the snap and vigorous beating of 
time to music. He begins with an exercise, such as forearm 
raising, inhaling and lowering, exhaling. This is repeated, 
singing "Ah," and then with the other vowels, then singing 
"Ah" on middle "C," running up to upper "C" over the octave 
with words of one syllable, in order to break the monotony of the 
voice and give it flexibility. 

The high-pitched falsetto or eunuchoid voice, which occa- 
sionally occurs in men otherwise normal, can be corrected, 
according to E. E. Clark, by a course of vocal gymnastics and 
singing exercises, beginning with a note of high pitch and then 
singing down the scale until the lowest possible note on the 
register is reached. The voice is then kept at this pitch, and the 
low notes are repeated ten or fifteen times. The patient is then 
taught to read aloud in the deep tone secured by singing his way 
down the scale. G. Hudson-Makuen secures the same result by 
training the patient to lower the position of the larynx during 
phonation. 

Where the utterance of intelligible speech is hindered or 
prevented by the convulsive and disorderly contraction of the 
muscles of respiration, phonation or articulation exercises of 

1 Journal of the American Medical Association, December 24, 1904. 



TIC, STAMMERING, AND CHOREA 



541 



skill must be employed almost exclusively, to restore the dis- 
ordered co-ordinations and to teach correct habits of breathing, 
phonation, and articulation. 

Stammering occurs in about i per cent, of school children. 
The London County Council report (1909), covering 19,303 
children, showed speech defects of some kind in 1.95 per cent., of 
which 1.3 per cent, were stammerers. Statistics show about 
1.22 per cent, in the German schools, whereas Hartwell's figures 
show about 0.78 per cent, among the children of Boston. 

Stammering is exceedingly contagious in a class and rapidly 
spreads among school children, making schools veritable nurseries 
for stuttering, according to Melville Bell. 





Fig. 45S- — The points of contact between the tongue and palate in the formation of the 
sounds L, R, and K (G. Hudson-Makuen). 

It has been attributed to the forcing of their education 
before the brain is sufficiently developed to govern the power of 
vocal utterance, so that a course of treatment would begin with 
gymnastic exercises such as described in Chapter XXVII for the 
breathing muscles, the first to function in the development of the 
child, while, later on, the muscles of phonation, and, lastly, 
those of articulation are trained. Treatment would thus be 
based on the preliminary development of the fundamental and 
intermediate mechanisms, ending with the finest and most 
specialized co-ordinations. 

Audible speech is caused by the blast of air driven from the 
lungs by the muscles of expiration through the slit of the glottis, 
bounded by the vocal cords, whose approximation is varied by 
the laryngeal muscles, into the mouth, where it is formed and 
modified by the muscles of the palate, tongue, and lips. The 



542 



EXERCISE IN EDUCATION AND MEDICINE 



complete production of speech then is effected by a co-ordination 
of muscles in the chest, throat, and mouth respectively. 

Stammerers will tell you that a prolonged struggle to speak 
is followed by a cramped exhausted feeling at the waist line, 
below the point of the sternum, a direct result of abnormal 
action of the diaphragm. 

G. Hudson Makuen lays special emphasis on the difference 
between ordinary passive breathing and the breathing of voice 
production or "artistic breathing," the function of passive 
breathing being simply to aerate the blood and eliminate waste 
matter, while breathing for voice production is to set the machin- 
ery of the voice in motion and to control this motion as a 
definite voluntary muscular process. The first muscular act in 






R 



Kand G 



Fig. 456.— The position of the tongue in producing the sounds L, R, and K (G. Hudson- 

Makuen). 



breathing for voice production is a slight inhalation, putting the 
respiratory muscles and the thorax into active position. He 
finds that nearly all speech defectives fail at this point. When 
this is done properly the column of breath raised upon the dia- 
phragm is ready for its impact against the vocal cords, an im- 
pact which must be made with the greatest nicety and control. 
This movement of expiration for voice production he attributes 
to the depression of the lower ribs by the diaphragm, a muscle 
of inspiration in ordinary respiration but of expiration in artistic 
breathing, in which it pulls the ribs downward and inward. 
Proper co-ordination of the intercostal and abdominal muscles, 
in addition to this action of the diaphragm, is, of course, essen- 
tial to the production of good tone. 



TIC, STAMMERING, AND CHOREA 543 

Among the respiratory exercises given at the Lewis Phono- 
metric Institute of Detroit are high-chest breathing, costal 
breathing, abdominal breathing, holding the palms over the 
region which is to be emphasized (Figs. 401, 402, 403). In 
diaphragmatic breathing the breath is inhaled by forcing down 
the diaphragm and expanding the entire circle of the waist. 
In this he is not in accord with Makuen's theory of artistic res- 
piration. Effusive breathing is also practised, a natural emission 
of the breath on the sound of the letter H. This is increased to 
expulsive breathing, a more forcible or explosive breathing 
violently exhaled on the sound of the letter H. 

Treatment of stammering should start by training respira- 
tory co-ordination by itself — first, by articulating a series of 
syllables, using for each a single expiratory effort, next by ex- 
ercising the muscles that control the vocal cords, and then by 
training the co-ordination between the muscles of expiration 
and the laryngeal muscles, since many stammerers vocalize 
at the wrong time, there being no column of air ready when 
the cords are in the right position, or vice versa. Finally, the 
muscles of the pharynx, the palate, the tongue and the lips, the 
organs of articulation which mold the voice into speech, are 
trained for their work. Where there is an organic defect in 
them, such as a shortening of the muscles, cleft palate, or hare- 
lip, this must be corrected, and the rest becomes a purely edu- 
cational process. 

Care must be taken to distinguish between lack of develop- 
ment, faulty habits, and disease in the speech center of the 
brain, for in the last class of cases the outlook is hopeless. 

The entire treatment of functional stammering and stutter- 
ing is based on the physical training and co-ordination of the 
mechanisms of speech, the proper use of the muscles of respira- 
tion with reference to voice production, the training of the vocal 
muscles, and the education of the muscles of articulation. Ex- 
ercises are given to instruct the patient in the elementary sounds 
of the language, how to shape the lips, or where the tongue is to 
be placed, and this training requires patience and perseverance 



544 EXERCISE IN EDUCATION AND MEDICINE 

until the defect is finally overcome. The success that has at- 
tended Hudson Makuen's clinic on speech defectives is in great 
part due to the care with which the breathing and vocal exer- 
cises are graded, and the excellence of his discipHne in enforcing 
their accurate, thorough, and persistent practice. 

There goes on hand in hand with these exercises a progress- 
ive training of the will, of concentration, of attention, and of 
self-confidence. The training of confidence spells victory in 
many cases. Mental uncertainty and doubt are inveterate 
enemies to the stammerer, the training of concentration and will- 
power being necessary if he is to maintain his improvement and 
prevent the constant tendency to relapse. 

Chorea is a disturbance of co-ordination characterized by 
irregular involuntary contractions of the muscles, accompanied 
by psychic disturbances and frequently by endocarditis. It 
occurs especially in abnormally bright, active-minded children, 
who are forced ahead of their grade in school and are subject 
to the excitement of competition for prizes. Girls are three 
times as Hable as boys. Will S. Monroe sent an inquiry to 
twenty-one teachers, thirteen of whom had i or more cases in 
each of their schools. Of the 24 cases, 16 were girls. 

While there are no constant anatomic changes found in the 
nervous system, the tendency to endocarditis is such that in 
no cases of autopsy the eft'ects were noted in nearly 100. 
Because of this great liability to endocarditis the heart should 
be carefully examined in all cases. The presence of a murmur, 
however, does not indicate endocarditis, since the disease occurs 
most frequently in nervous young girls in whom heart murmurs 
are almost the rule. The duration of an attack is very variable, 
from two or three weeks to the same number of months, with 
an average of about eight or ten weeks. 

The disease is easily spread by psychic contagion, hence 
the necessity for early diagnosis and isolation. 

Every choreic child passes her novitiate of restlessness — mus- 
cular twitching of the arms, shoulders, and legs, awkwardness in 
the execution of delicate tasks, exaggerated movements of the face 



TIC, STAMMERING, AND CHOREA 545 

muscles, wrinkling of the forehead, and knitting of the eyebrows, 
early evidences that are apt to be overlooked or misunderstood. 

Teachers should be on the lookout for abnormal movements 
in the muscles of the face and hands, alteration in the pupil's 
temper, the loss of willingness and ability, unusual signs of 
mental or bodily degeneration, headache, or pains in the limbs. 
Perhaps the best index is the hand. Bid the child to hold up 
both hands openly with extended arms and palms toward you. 
If this is done steadily, both hands upright and both alike and 
nothing to choose between the positions of the two, then the 
child has not, nor is it near, St. Vitus' dance. If there is tremor 
of the thumbs and fingers when the hand is placed on yours, 
palm to palm, suspicion would be aroused. 

The treatment of the acute attack consists of rest, isolation, 
and tonics. Where the jerky movements have abated the 
application of general massage is of value, and the importance of 
gymnastic exercise cannot be overestimated during convalescence. 
When the acuteness of the attack has subsided, the treatment 
should begin with massage for the first few days, followed by 
simple, slow, passive or resisted movements, in which the limb 
is held quiet for a few minutes, and then rhythmic passive move- 
ments in which the patient should take no active part. The 
patient will oppose these movements by the inco-ordinate jerky 
efforts due to the disease. Later on, rhythmic exercises suffi- 
ciently active to tire the muscular system moderately will be in 
order. These should be done with the patient by herself, if pos- 
sible, and any excitement or competition of class drills should be 
sedulously avoided. If the exercises are taken in company with 
others, the patient should be placed in the back row of the class. 

The keynote of such treatment is the rhythmic repetition of 
simple movements to overcome the irregularity of the twitch- 
ing, and great strain on the attention or fatigue of the patient 
should be eschewed. The practice of simple dancing exercises 
to music is of the utmost service, emphasizing the rhythm and 
taking away the mental strain necessary to follow movements 
done to command. 
35 



CHAPTER XXXII 

INFANTILE PARALYSIS FROM ANTERIOR POLIO- 
MYELITIS 

Anterior poliomyelitis is a lesion which destroys or impairs 
the motor paths found in the anterior horns of the spinal cord. 

It is probably a specific infection, although the history of a 
fall or other accident so frequently precedes an attack that it is 
difficult to consider it as a mere coincidence. When no such 
history exists the onset is without warning, and varies from 
slight feverishness to violent vomiting, high fever, and retraction 
of the head. The resulting paralysis follows in its severity the 
severity of the acute attack in a general way. Next morning the 
paralysis may be noticed, or it may not be observed for weeks, 
especially in young children in whom the wasting of the muscles 
is completely masked by the presence of fat, and the coldness 
of the limb may be the first symptom to cause anxiety. 

While the paralysis is "characteristically random" (Gowers) 
and seems to vary in different epidemics, the following statistics 
shows the relative frequency of the regions involved: 

T.\BLE Showing the Distribution of Paralysis in 1322 Cases Observed by 

DiCHENNE, SULIZMULLER, SiNKLER, StARR, jMacPhAIL, LOVETT, AND LUCAS. 
Region. Cases. 

Left leg 382 

Right leg 348 

Both legs 345 

Arm and leg, same side 59 

All four extremities 54 

Right arm 35 

Abdomen and trunk 32 

Left arm 28 

Three extremities 16 

Arm and leg, opposite sides 15 

Both arms alone 8 

Total . 1322 

S46 



INFANTILE PARALYSIS FROM ANTERIOR POLIOMYELITIS 547 

In the Lovett and Lucas series of 478 cases, in which the 
legs were affected, the anterior group (extensor longus digitorum 
and proprius hallucis) were affected in 92; the internal group 
(tibialis anticus and posticus), in 40; the external and peroneals, 
in 31; and the posterior group, in 45, the most frequent combina- 
tion being the posterior and internal (34), the anterior and 
internal (29), and the anterior and external (27). The tibialis 
anticus alone was affected in 95 cases. 

It will thus be seen that the internal group are most fre- 
quently affected, either singly or in combination. The quadri- 
ceps of the thigh was the muscle most frequently attacked 
(305 cases) by itself, or as one among several groups. 

Deformities make their appearance sooner or later in ne- 
glected cases. They result from the weight of the body coming 
on the structures imperfectly supported by paralyzed or weak- 
ened muscles, or by the weight of some part dragging and 
stretching these structures. The foot may turn in, the knee may 
become overextended, the hip dislocated, or scoliosis and winged 
scapulae may appear. Another series of deformities are the 
result of muscular action unopposed by their natural antagonists. 
These unopposed muscles cause distortion of one or more joints 
by their continual pull, which is not balanced by their paralyzed 
or weakened opponents. Such deformities are flexion of knee and 
hip, scoliosis, and various distortions of the foot, accompanied 
by muscular contractions on the shortened side. 

It can be predicted in advance what deformity a definite 
muscular paralysis will produce. The following table from 
Lovett and Lucas^ gives the chief deformities of the foot and 
their causes: 

Deformity. Resulting from paralysis of — 

Varus Peronei. 

f Anterior tibial, 
j Posterior tibial. 
. J Both tibials. 

' Flexor longus hallucis. 

Whole leg (weakened). 
Complete paralysis. 
Journal of American Medical Association, vol. li, 20. 



548 



EXERCISE IN EDUCATION AND MEDICINE 



Deformity. 



Resulting from paralysis o£- 



Equinus . 



j Anterior muscles paralyzed or weak. 
I Complete paralysis (from dangling). 



Equino varus. 



i 



'^\nterior muscles (with persistance of 

flexor longus hallucis) . 
Anterior and external group. 
Paralysis apparently complete. 
I Anterior and internal muscles. 
I Anterior muscles and weight-bearing,. 

Calcaneus Posterior muscles. 

Calcaneo valgus Posterior muscles and one or both tibials. 



The groups involved may be discovered by wasting of the 
muscles, by electric stimulation, and by careful examination 
of the actions that the patient can perform. The voluntary 
movement present must be estimated with great accuracy, and 





Fig. 457. — Incorrect position for test- 
ing the action of the triceps. 



Fig. 458. — Correct position for testing the 
action of the biceps. 



the difficulty of this has been insisted upon by Beevor, in his 
Croonian Lectures on Muscular Movements (1903). 

Among the fallacies that may occur are the confusing of the 
action of gravity for muscular action. A slow relaxation of the 
active biceps may be confounded with contraction of the triceps 
when the bent arm is slowly straightened when hanging at the 
side, whereas if the arm be first flexed, and the elbow be held at 



INFANTILE PARALYSIS FROM ANTERIOR POLIOMYELITIS 549 

the level of the shoulder and the patient told to extend it, he will 
be unable to do so (Figs. 457, 458). 

Another error that must be guarded against is the crediting 
of a muscle with contractile power when the movement is the 
result of the action of accessory muscles. In flexing the arm 




Fig. 45g. — Correct position for testing the action of the flexors of the elbow. The swing- 
ing of the arm is thus prevented. 



where the biceps is affected, the contraction of the supinator 
longus and brachialis anticus may disguise the true lesion. 
The habit that patients acquire of jerking the arm or leg upward 
or forward, and so simulating the movement of muscles which 
are actually inert, must also be detected (Fig. 459). These 
fallacies should be demonstrated to the patients themselves or 



5 so EXERCISE IN EDUCATION AND MEDICINE 

their parents, in order that they may not be deceived as to the 
actual condition present. During the acute onset of the disease, 
and the days of pain and sensitiveness that follow, absolute rest, 
with support of the limb in its normal position, is essential to 
prevent the overstretching of the weakened muscles. In a 
week or ten days, when friction and movement can be borne 
without pain, the reconstruction treatment may be started. 
The weakened muscles must be kept in a relaxed position, for 
overstretching has a marked influence in producing degenera- 
tion of an impaired group. A spHnt should be fitted on the leg 
and foot to keep the ankle at right angles and prevent the pres- 
sure of the bedclothes from overextending it. This point has 
been well insisted upon by A. H. Tubby and Robert Jones. ^ The 
circulation must be fostered by extra covering. A paralyzed limb 
is colder than its fellow. An extra flannel sleeve or leg or a 
sheath of rabbit skin will raise the temperature and give the 
muscles and joints the blood-supply necessary to keep up their 
nutrition and prevent atrophy. By such means the shortening 
of a leg during the growing period may be avoided. The action 
of impaired muscles must be cultivated with the greatest solici- 
tude, keeping up their tone and nourishment by massage, volun- 
tary movement, and electricity. 

There is almost always present in a paralyzed limb some 
muscular power and action that is latent and unsuspected, and 
it will not become available unless cultivated and developed. 

In this part of the treatment the co-operation of the parents 
and patient is essential. It is an educational rather than a 
medical problem, and what can be done by intelligent co-opera- 
tion of doctor and parent has been well described by Earl Barnes 
in the account of his little daughter's case, which I can recom- 
mend for the encouragement of parents with a similar problem.- 

Both ingenuity and perseverance are required in devising 

1 Modern Methods in the Surgery of Paralysis ('jMacmillan & Co). 

"Earl and Anna Barnes, "A Case of Infantile Paralysis" (privately printed); 
also "The Education of A Partially Paralyzed Muscle," Earl Barnes, Transactions 
of International Congress on Hygiene and Demography, Washington, D. C, 191 2. 



INFANTILE PARALYSIS FROM ANTERIOR POLIOMYELITIS 55 1 

and carrying out the voluntary exercise so necessary to awaken 
the latent action of an impaired muscle. Strapping the feet to 
a tricycle which is pushed about; supporting the weight under 
the arms by a frame on wheels which just allow the feet to touch 
the floor, will help to start the first movements in the limb. 
Placing the child in a bath and having the movements done 
under water will sometimes reveal a slight action that was pre- 
vented by the weight of the leg. This may be advantageously 
combined with salt and the benefits of salt-water bathing added. 
Exercise may be done before a mirror, and care must be taken 
in designing them not to overexercise the strong groups and so 
increase the deformity. 

A daily program of massage and exercise should be written 
out and conscientiously adhered to; as Earl Barnes says, "No- 
where in the long process of recovery is there any place to stop 
nor any reason to be discouraged." 

Massage should be started as soon as the pain and sensitive- 
ness have disappeared. It should be done twice a day if possible 
and not less than once in twenty-four hours. Deep pressure and 
rolling of the tissues in one or both hands alternating with slow 
frictions from the periphery to the center are best, the object 
being to act on the blood-supply and nutrition of the muscles 
and joints. The heat of the hand in massage and manipulation 
also has a helpful influence on the circulation. Owing to the 
expense of a trained masseur the mother should take instruc- 
tion in the art, so that it may be kept up continuously at home 
or abroad, and from time to time her work should be inspected 
and corrected by an expert. Manipulation of the joints should 
also be systematically practiced to keep the muscles and liga- 
ments normally stretched and to prevent contractures and de- 
formity. It is probable that the passive movement of a joint 
throughout its normal range has a direct influence on the nerve- 
centers whether normal or impaired. 

Vibration is of value in stimulating the circulation and 
its administration is readily learned, although the tendency is 
usually to give too much. Two minutes over and about a joint 



552 EXERCISE IN EDUCATION AND MEDICINE 

with the medium stroke of the vibrator is sufficient for a treat- 
ment. 

One of the chief difficulties in the administration of elec- 
tricity is the pain, which is badly borne by young children. 
The sinusoidal current is the least painful form, and by its 
means rhythmic contractions of the muscles can be obtained 
sometimes where voluntary action is impossible. While its use 
is limited to this action it should not be ignored. The groups 
to be treated should first be placed in a relaxed and shortened 
position, and the application should never continue more than 
two minutes on one muscle. 

The prognosis for complete recovery in a long-paralyzed 
group is not good, but gradual restoration of power may con- 
tinue throughout years, depending on the thoroughness of the 
treatment. Neglected cases quickly develop contractures 
and deformities, with stretching and strophy of the weakened 
muscles and shortening of the affected limbs. 

The treatment by braces and tendon transplantation does 
not come within the scope of this work, but braces at least are 
almost always required during some part of the treatment. 

In Earl Barnes' carefully observed case we find that "M," 
at eighteen months, had a complete paralysis of all four limbs, 
with recovery in arms only in two weeks, then slow recovery in 
the right leg and later on in the left. After eight years persist- 
ent treatment her back is straight, and the only persistent 
deformity is a slight shortening of the left leg (| inch) and 
absence of power to flex the left foot. She can walk miles, 
swim, and play all the games of other children of her age. If 
neglected she would have had club-foot, the left leg would 
have been greatly shortened with pelvic displacement and 
marked scoliosis, and consequently more or less invalidism. 

This case is typical of many in which similar good results 
are obtained by the intelligent and persistent appKcation of 
these corrective and educational methods. 



CHAPTER XXXIII 

TREATMENT OF LOCOMOTOR ATAXIA BY 
EXERCISE 

Habitual movements, such as walking, are accomplished 
with harmonious muscular action and the least possible muscular 
effort. 

The movements are performed accurately, exactly, economi- 
cally, and gracefully. When such movements become jerky, 
exaggerated, wavering, or chaotic we call them ataxic. This 
condition or symptom is present in many diseases of the nervous 
system. Lesions of the cerebrum, cerebellum, spinal cord, and 
peripheral nerves may induce it, but the most frequent cause is 
tabes dorsalis, or degeneration of the posterior roots and columns 
of the spinal cord, produced by exposure to cold, syphilis, or some 
other acute poisoning of the nerve tissue. 

In reading the literature on this subject one is struck by the 
multitude of theories and the inadequacy of any one of them to 
explain all the symptoms. 

The hypothesis that is of most interest in connection with 
the application of exercise is that of Edinger, called the exhaustion 
theory, which is that the cells of the body are normally in a state 
of equilibrium, one with the other, so that if a cell becomes weak- 
ened by disease other cells lying about it will crush it out in 
their growth. Again, when the amount of work required from a 
group of cells is too great, even if their vitality be perfectly 
normal, they may succumb simply from their inability to recu- 
perate and regain the loss of tissue due to their excessive activity. 
A similar condition is found in occupation palsies. The nutrition 
of the cells may be impaired through toxins circulating in the 
blood, especially if they have a selective action on certain parts 

553 



554 EXERCISE IN EDUCATION AND MEDICINE 

of the nervous system, and nearly go per cent, of tabetic patients 
show a history of syphilis. The exhaustion theory would help 
to explain the frequency of the first appearance of ataxia in the 
lower extremities, the neurons governing them being constantly 
employed in the maintenance of equilibrium. 

Cases may be cited where ataxia has first appeared in the 
arms owing to overfunctioning. One case reported by Mott 
occurred in a mounted policeman, in whom the symptoms 
started in the arm with which he held the horse's reins. 

In tabes the sensory nerves may be aft'ected, and the eyes 
show a characteristic optic atrophy with the Argyll-Robertson 
pupil. Men being more exposed to these fatigue influences 
than women, we would expect to find its frequency greater among 
them, and the proportion is actually about ten to one. James 
Stewart noted its frequency among lumbermen who have lived 
a hard life in the logging camps during the winter and spring 
months. 

The relief of ataxia does not aft'ect the underlying structural 
change, yet this symptom is so distressing that its alleviation is 
among the greatest boons of therapy. 

The motor symptoms are first noticed as increased clumsi- 
ness, especially in the dark, or difliculty in maintaining the 
equilibrium when washing' the face with the eyes shut (Osier). 
When the patient stands with feet together and eyes closed he 
sways to the point of falling if the surgeon does not steady him 
(Romberg's symptom). On turning or stopping quickly he is apt 
to fall. He leans upon a stick in walking, the eyes fixed on the 
ground, the body inclined forward, and the legs wide apart. 
The leg is thrown out violently, the foot raised too high and 
brought down with a stamping movement on the heel. In the 
arms it may be first noticed through his difliculty in buttoning 
his coflar, or in other simple acts. With comparatively advanced 
ataxic symptoms he shows little alteration in the size, strength, 
or nourishment of the muscular system. There is, however, 
always present in typical cases along with certain sensory dis- 
turbances hypotonia, or lack of muscular tone, which allows the 



TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 555 

stretching of muscles and permits the joints to move far beyond 
their normal range (Fig. 460). 

The ataxic symptoms may be classified as (a) abnormally 
rapid movements; {b) exaggerated muscular exertion in per- 
forming simple actions; (c) prolonged contraction, continuing 
after the movement has been completed; and {d) jerky staccato 
progression. 

Although ataxia is the only symptom of tabes dorsalis that 
can be reached by exercise, it is frequently the one symptom 
which keeps a patient bedridden, the others not being severe 
enough to interfere with his regular course of life. 

The exercise treatment is based on the possibility of educat- 
ing the impaired central nervous system and re-establishing the 




Fig. 460. — Hypotonia of the muscles of the pelvis and spinal column (Frenkel). 

lost or enfeebled co-ordination and sensibility. The symptom 
against which it is directed is a motor disturbance, which has 
its origin not in a diminution of the muscle's motor power, but 
in a loss of sensibility in them, and it is based on the capacity 
of the neuromuscular system for education so long as the motor 
apparatus itself is intact. It consists in relearning the habitual 
movements disorganized by disease, a task which in principle is 
identical with the acquisition by a healthy person of a com- 
plicated feat involving a nice adjustm^ent of muscular action, 
such as juggling or balancing. Reliance must then be placed 
mainly on exercises of skill, alternating with passive movements 
and massage, as a relief to improve the nourishment of the 
muscles without continuing the demand on the rapidly tiring 
will-power. 



556 



EXERCISE IN EDUCATION AND MEDICINE 



The exercise treatment of ataxia has been popular for many 
years in Sweden, and was used forty years ago in America by 
Dr. Weir Mitchell, but many of the devices employed have been 
invented by Frenkel, of Heiden, and are for the first time de- 
scribed in his work on tabetic ataxia,^ 
from which some of the accompany- 
ing illustrations are taken. The treat- 
ment depends on four rules — namely: 
(i) The initial movements are 
simple and uncompHcated. 

( 2 ) The succeeding movements are 
carefully graduated in difficulty. 

(3) The movements are conscien- 
tiously performed. 

(4) The movements are directed 
by the aid of vision. 

The initial simplicity of the exer- 
cise varies with the extent of the dis- 
ability. In attempting to rise from 
a chair the tabetic patient usually 
neglects to draw the feet backward, 
and so finds himself unable to rise 
without assistance. He has to learn 
this simple co-ordination all over 
again. 

Movements of walking forward, backward, and to the side 
with steps of measured distance should next be practised. For 
this purpose the floor may be painted with black lines, or with 
footprints at measured distances (Fig. 461). If lines be drawn 
zigzag on the floor the continual change of direction makes this 
walking exercise much more exacting to the patient, and any 
irregular pattern on a carpet can be used for this purpose. 
When these simple movements have been mastered, walking 
up- and down-stairs with the use of a banister should be prac- 
tised. A special stairway, designed by von Leyden, has two 
^Tabetic Ataxia, by H. S. Frenkel (Blackiston & Co). 




Fig. 461. — Walking exercise. 



TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 557 

banisters, and the steps are cut so that the foot must be placed 
down accurately at each step (Fig. 462). 

The greatest precautions must be taken to prevent the 
patient from falling m this exercise and so becoming timid or 
discouraged. A belt with a handle or strap attachment should 




Fig. 462. — Dr. von Leyden's stairway used for exercises to re-educate the lost co- 
ordination in locomotor ataxia cases (Pennsylvania Orthopaedic Institute and School of 
i\Iechano-Therapy (Inc.), Fhila.). (Courtesy of Dr. Max J. Walter.) 



be placed about the waist, and an attendant should always be 
ready to catch him if he shows signs of losing his balance. Exer- 
cise of the lower extremities can be carried on in bed, where the 
disease is too far advanced to permit of walking or standing. 
He is told to touch the great toe of one foot with the heel of the 
other, then to run the heel upward along the front of the shin 



558 



EXERCISE IN EDUCATION AND MEDICINE 



to the knee (Fig. 464) and back again. Another exercise is the 
placing of the heel of either foot in notches cut in a board, as 
shown in the illustration (Fig. 465). If the patient be seated in 




Fig. 463. 

front of a set of movable pins, he can exercise by kicking them 
in turn, the attendant naming the one that he must touch 
with his foot (Fig. 466). 




Simple movements such as these will cause rapid exhaustion, 
and the pulse-rate must be carefully watched and the exercise 
stopped short of fatigue. 

The upper extremity may be trained by taking a wooden 
block, about 18 inches long and triangular in section, so pre- 



TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 559 




Fig. 465. — Notched board (Frenkel). 




Fig. 466. — Dr. von Leyden's ten-pin arrangement used for the re-education of lost 
co-ordination in locomotor ataxia cases (Pennsylvania Orthopaedic Institute and School 
of Mechano-Therapy (Inc.), Phila.). (Courtesy of Dr. Ma.x J. Walter.) 



56o 



EXERCISE IN EDUCATION AND MEDICINE 



pared that one edge remains sharp, a second beveled off, while 
the third has a curved groove. The block is placed on a table 
in front of the patient in a position indicated by the drawing 
(Fig. 467), with the grooved edge up. He is requested to draw 
the point of a stout pencil or pointer along the groove from the 
farther end of the block toward him, at the same time holding 
his fingers and wrist-joint perfectly stiff. The object of the 
exercise is to teach him to keep his arm raised in a definite 
position and to make simple excursions in the horizontal plane. 




Fig. 467. — Triangle block for the hand co-ordination (Frenkel). 



This exercise is by no means easy, especially when the pencil 
has to be held with the slightest force. At first it will often 
leave the groove, but with practice its progress becomes more 
steady, although scarcely ever free from wabbling. 

It is usually a great surprise to a patient on his first ex- 
amination to find that he is unable to place his finger to his 
nose with the eyes closed. This simple exercise may be prac- 
tised and varied in numerous ways. Frenkel uses a perforated 
board (Fig. 468), the tip of the forefinger being placed in the 



TREATMENT OE LOCOMOTOR ATAXIA BY EXERCISE 56 1 

numbered hole called out by the attendant. It can be made 
more difhcult by having him insert pegs into the holes. 




Fig. 468. — Perforated board (Frenkel). 




Fig. 469. — Colored balls swinging (Frenkel). 

When this co-ordination is sufficiently improved he may 
"be advanced to the catching of colored balls swung from a 
horizontal bar and caught on the swing (Fig. 469), and he may 
36 



562 EXERCISE IN EDUCATION AND MEDICINE 

be set to copying diagrams with a pencil. As soon as he shows 
signs of flagging interest his task should be replaced by another 
set of exercises. 

Along with these set of exercises he should be trained in the 
useful operations of dressing and undressing himself, helping 
himself at the table, using pen and ink, and other procedures that 
come up in the course of the day. 

The exercises are useful only when the attention is fully 
concentrated on them. This necessity for concentration, and 
the excessive muscular exertion required to perform simple 
acts, the fear of accidents, and the annoyance which he feels, 
especially at the beginning of the treatment, because his Hmbs 
will not obey orders, all combine to produce rapid and profound 
fatigue, and the practice of any movement should not be con- 
tinued for longer than three or four minutes. In severe cases, 
where nutrition is impaired, one-half to one minute will be quite 
sufficient until he has become strong enough to bear the strain 
of longer-continued practice, and no new exercises should be 
begun until there is complete recovery from the excitement 
and fatigue of the previous one. 

John K. IMitchelP gives the exercises used in the Philadelphia 
Orthopaedic Hospital, recommending their simplicity and avail- 
ability for use in a private house. The only apparatus used is a 
short flight of steps and a wall ladder. In bad cases exercises 
begin with simple flexions of the legs, the patient recumbent, 
head raised so as to see the lower limbs. These are continued 
in mild cases for three or four days, alternating with massage. 
As he says, "An ataxic may collapse without a moment's 
notice." 

Maloney advocates certain important modifications of 
the Frenkel treatment, based on the fact that the blind show 
less impairment of co-ordination than patients whose vision is 
normal. He also emphasizes the power of fear to aggravate or 
precipitate ataxia in those not previously afflicted. His treat- 
ment consists of: 

^ A. P. E. Rev., vol. xiv, p. 346. 



TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 563 

(i) The teaching of muscular relaxation. 

(2) The instruction of blindfolded patients in co-ordinate 
movements. 

(3) The minimizing of fear. 

The only apparatus he requires is a mask to bhndfold the 
patient and some strips of linoleum of varying width. So blind- 
folded, the patient is placed recumbent and instructed to relax 
in turn the muscles of the neck, trunk, upper and lower ex- 
tremities, to ehminate all misdirected muscular contraction 
which may have arisen from ill-judged attempts to balance 
and concentrate the attention upon the muscular sense impres- 
sions. 

This differs from Frenkel. By blindfolding the patient 
he claims that the enormous amount of attention pre-empted 
by vision is hberated and can be devoted to the more accurate 
interpretation of posture. The movements given are first pas- 
sive, then dupKcate, and, finally, active, the joints being taken 
in turn. He begins progression by creeping with carefully padded 
knees on a strip of linoleum, which serves to give direction. 
From creeping the patient graduates to walking barefoot on 
linoleum strips, which is narrowed as skill advances. 

Tabetic patients have more or less completely lost the sense 
of fatigue, consequently, in determining whether he is tired 
or not, signs of inattention, quickened breathing, and rapid 
action of the heart will be the most reliable guides. The pulse 
usually rises to 120 or even 160 beats a minute, in direct pro- 
portion to the difficulty of the movement. It should be the 
routine practice, therefore, to examine the pulse at the beginning 
of the treatment and frequently throughout it, and to interrupt 
the work by a period of rest as soon as the pulse-beats approach 
150. 

The interval of rest should last until the heart-rate approaches 
normal again, although in most cases the pulse will remain a 
trifle above its usual rate. If it becomes unduly frequent after 
slight exertion it is a sure sign of tabetic cachexia, and such 
patients must be treated with the greatest caution. ,^^ ^ 



564 EXERCISE IN EDUCATION AND MEDICINE 

The exercises are for co-ordination and not to increase the 
muscular power, therefore exercises requiring much expenditure 
of strength are not of proportional value as a training in co-ordi- 
nation and so must be considered harmful. 

Two periods of exercise a day are the average rule of prac- 
tice. To go beyond that is to go into the danger zone, unless 
each seance be made short and the patient is robust and deter 
mined to make rapid progress, in which case three periods may be 
given. In the morning he takes the movements designed for 
the recumbent position, which are the easiest. In the afternoon 
he may have fifteen minutes of walking exercise with frequent 
rests. If the amount be properly regulated, each successive 
exercise should be followed by an increase in control, so that 
at the end of a period he should feel more fresh and vigorous 
than before starting. It is wise in some cases to substitute for 
one period a general massage or electric treatment, which has 
the great advantage of resting the patient's will and attention 
and improving the nutrition. 

The unfailing certainty of the improvement, and the fact 
that it is the improvement of a symptom caused by an organic 
lesion, attaches unusual interest to this treatment. The hypo- 
tonia and common sensory symptoms may remain practically 
unaffected, although very frequently they seem to improve, 
probably because the patient's mind is diverted from pain and 
directed to the acquirement of muscular skill. The improvement 
in muscular control may remain for years, and when the ataxia 
does increase again a course of exercise will once more bring 
it under control. 

The ideal result would be the restoration of the normal 
accuracy, control, and velocity of the movements, a result which 
Frenkel claims to have achieved in many cases. The restoration 
in locomotion is, however, generally sufficient to enable the 
patient to resume his usual business or profession, and this is all 
that may be expected. In one case coming under my own ob- 
servation, treated by John K. Mitchell at the Orthopaedic Hos- 
pital of Philadelphia, and not by any means an unusual one, a 



TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 565 

miner from California, who came bedridden accompanied by 
an attendant, improved to such an extent that he was en- 
abled to travel across the continent by himself and resume the 
active management of his mines. 

In giving a forecast of the progress to be expected in any 
case the natural disposition, the alertness, and the ability for 
muscular exercise must be found out and given full weight by 
the surgeon. The more skilful patients will make more rapid 
progress, and the best results are obtained among those who 
have been accustomed to work demanding dexterity, or who 
have been successful devotees of athletic sports, men who have 
lived a good deal in their muscles, and who have at one time had 
the muscular sense well developed. 

Another important factor is the patient's personal courage. 
Apprehensive or cowardly patients will not risk the sHghtest 
movement without support or attention, and will have to prac- 
tice for a long time before much definite improvement can be 
noticed. Wilham Burdick reports the case of a contractor and 
builder who, from a houseridden invahd, recovered to the extent 
of being able to walk along the 2 -inch stringers in the third 
story of a house he was building.^ 

The longer and more thoroughly a course is continued, the 
more certain and lasting will be the improvement, and the closer 
will the patient approach to the normal in motor capacity and 
accuracy of movements. 

^ "A Study of Functional Exercises in Some Nervous Diseases," New York 
Med. Journal, September 10, 1910. 



NDEX 



Abbott's apparatus treatment of sco- 
liosis, 458 
Abdominal hernia, bicycling in, 469 
causes of, 463 
Championniere on, 469 
diagnosis of, 460 
exercise for, 466-469 
Harvey on, 460 
object of exercise for, 465 
prognosis of, 470 
Seaver truss pad for, 464 
symptoms of, 463 
typical cases of, 469, 470 
weakness, exercise in treatment of, 459 
Abrams' heart reflex of contraction, 346 

on spondylotherapy, 345 
Accidents in college athletics, 264 
Active exercise, 17 
Adolescence, growth of heart in, 54 
Age, regulation of exercise to, 54 
Aged, effects of exercise on heart in, 55 
Albumin in normal urine, 70 
Albuminuria after exercise, 70 

in Marathon runners, 71 
Allbutt on dilatation of heart, 45, 46 
Amaros, 99 

pioneer in French gymnastics, 127 
Amateur Athletic Union, formation of, 
144 
standing of college athletes, 264 
Y. M. C. A. Athletic League, defini- 
tion of, 172 
American adaptation of German system, 
107 
colleges, German system in, 241 
intercollegiate games, first, 144 
Playground Association established, 
187 



American Playground Association, ori- 
gin of, 103 
standard tests of, 209 
work of, 188 
Posture League, chart of, 224 
Anderson on mortality in ex-athletes, 61 
Andover, compulsory athletics at, 148 
Aphasia, Mills' treatment of, 540 
Apparatus, exercise on, for women, 282 
exercises for blind, 290 
gymnastic, classification of, 82, 83 

original uses for, 82 
in Swedish system, 123 
Archery for women, 284 
Armstrong's observations in ex-runners, 

61 
Arterial tension, measurement of, 42 
Arteriosclerosis, Bad Nauheim treat- 
ment, 502 
Battle Creek Sanatorium treatment 

for, 502 
causes of, 496 
characteristics of, 496 
exercise in treatment of, 498 > 
Kellogg on, 498 
massage in, 498 

Oertel's walking exercises for, 497 
Schott treatment for, 502 
Stokes on, 499 
Zander vibrator for, 498 
Arthritis deformans, Graham on, 334 
massage for, 334 
passive movements for, 334 
vibration for, 334 
Articulation, importance of, to deaf- 
mutes, 300 
Artificial respiration, Schaffer's method, 
35 

567 



568 



INDEX 



Athenians, physical education of, 146 
Athlete, typical college, measurements 

of, 269 
Athletes in training, Weyman on, 44 

massage for, 340 
Athletic condition, Crampton's test for, 

43 

exhibitions of playgrounds, 210 

field, construction of, 149 

games, therapeutic wastefulness of, 81 

League of Y. M. C. A., 171 

meets, school, classification of com- 
petitors, 232 

records of men and women, com- 
parison of, 273 
Athletics, college, modern development 
of, 145 

compulsory, at Andover, 148 

introduced into French schools, 148 

physical education by, 143 

revival of, in France, 129 

track and field, events of, 150 
Ayer and McKenzie on heart murmur. 



Back-and-leg lift, blood-pressure in, 51 
Backward children, benefits of segrega- 
tion of, 309 
rhythmic exercises for, 310 
sensorial gymnastics for, 309 
special classes for, 307, 308 
schools for, 309 
Bad Nauheim treatment of arterio- 
sclerosis, 502 
Baden-Powell, founder of Boy Scouts, 

179 
Ball games, development of, 143 
Ballentine on physical education of 

women, 274 
Bancroft on "Games for Playgrounds," 
206 
on round shoulders, 396 
tests of bad posture, 224 
webbing for round shoulders, 408 
Bantam posture, 225 
Barach and Savage on urine of Marathon 
runners, 71 



Barr on feeble-minded, 311 
Bartsch's danger scale for sports, 62 
Baseball, modified, for blind, 293 
Basedow, originator of German system, 

95 

Bath-houses, municipal, 212 

Baths, municipal, 184 

Battle Creek Sanatorium surveys for 
walks, 501 
treatment for arteriosclerosis, 502 

Beard on Boy Scouts, 179 

Bergonie's electric treatment of obesity, 
526 

Bicycling in abdominal hernia, 469 

Binet-Simon measuring scale for intelli- 
gence, 306 
Goddard's revision of, 306 

Bishop on Delsarte, 135, 136 

Blind, apparatus exercises for, 290 
appliance for foot-racing, 292 
beginning exercises for, 287 
children, measurements of, 287 
cock-fight game for, 290 
compulsory exercise for, 289 
corrective exercises for, 288 
cultivating physical confidence in, 288 
girls, physical education of, 296 
Japanese torpedo game for, 290 
modified baseball for, 293 

football for, 293 
outdoor apparatus for, 289 
Overbrook School for, 287 
prevention of accidents to, 288 
rubber ball game for, 291 
size of gymnasium classes of, 289 
special gymnastic apparatus for, 288 
Swedish gymnastics for, 290 
swimming for, 293 
track sports for, 293 
Van de Walker on, 292 
walking for, 292 

Blood-count, Hawke's experiments on, 

34 
Mitchell's experiments on, 34 
Blood-pressure, Crampton's test of, 43 
effect of exercise of endurance on, 53 
in back-and-leg lift, 51 



INDEX 



569 



Blood-pressure in training, Weyman on, 

44 

in two-twenty-yard race, 51 

McCurdy on, 51 

Stamp on, 51 
Body, untrained, condition of, 72 
Boston gymnasium, 104 

municipal playgrounds of, 186 

Norman School of Gymnastics, 114, 

275 
Boudet's vibration helmet, 353 
Bowling for women, 284 
Boy Scouts, Beard on, 179 

founded by Baden-Powell, 179 

good work of, 182 

in Europe, military idea of, 181 

in United States non-military, 181 

merit badges given by, 181 

object of, 180 

rapid increase of, 1 79 

subjects taught by, 180 
Boys, gang instinct in, 76 
periods for games of, 75 
physical evolution of, 76 
Brackett on scoliosis, 424 
Branting successor to Ling, in 
Breathing exercises, effects of, 491 

in tuberculosis, 481 
Breathlessness, facial expression in, 23 
Broad on massage for knee injuries^ 332 
Broad jump, arrangement of ground for, 

155 
distances for, 155 
standing, 156 
Brooks' examinations of hearts of ex- 
athletes, 59 
Brunton's observations on systolic pres- 
sure, 42 
Burns on municipal playgrounds, 192 
Business men, Y. M. C. A. program of 

exercise for, 168 
Butler on tuberculosis, 491 

Caledonian athletic meets, 143 
Call on Delsarte, 135, 137 
Camp-fire Girls, 179 
call of, 183 



Camp-fire Girls founded by Gulick, 
182 
idea of, 182 
membership of, 182 
subjects taught by, 182 

Cannon-ball massage for constipation, 
476 

Carbon dioxid, effect on muscular con- 
traction, 38 

Central Committee for Promotion of 
Sports in Germany, 103 

Championniere on abdominal hernia, 
469 

Charles Bank playground, 186 

Charleyhorse, 31 

Chicago Y. M. C. A. Training School, 
166 

Child Study Committee of Detroit, 308 
three objects of exercise for, 214 

Childbirth, effect of exercise on, 279 

Childhood, games and exercises of, 74 

China, introduction of physical training 
in, 166 

Chiosso's polymachinon, 365 

Chorea in school children, 544 
massage for, 545 
treatment of, 545 

Circulation, effect of exercises of effort 
on, 50 

Circulatory diseases, exercise for, 493 

City children, outdoor exercise for, 88 
dwellers, increase of, 184 
exercise for, 87 
recreation places for, 88 
life, evils of, 184 

physical degeneracy from, 184 

Civilization a factor in underexercise, 88 

Civilized man, physical superiority of, 
248 

Clark's treatment of falsetto voice, 540 

Class leaders at University of Pennsyl- 
vania, 266 

Classification of athletic games and exer- 
cises, 17, 79-81 

Clias, 99, 127 

Club-foot, 371 

Cock-fight game for blind, 290 



57° 



INDEX 



College athletes, amateur standing of, 
264 
medical examination of, 263 
scholastic standing of, 264 
training table for, 263 
athletics, accidents in, 264 
modern, development of, 145 
one-year residence rule of, 264 
regulations of, 263 
standard of scholarship in, 263 
gymnasium, divisions for various 
sports, 257 
swimming pool for, 258 
men, graded exercise for, 247 
women, physical defects of, 277 
Colleges, physical education in, 240 
Colles on exercise for inebriates, 335 
Competitive sports for playgrounds, 209 

for women, 283 
Compulsory gymnastic instruction in 

German schools, 102 
Concentric circle plan of playgrounds, 

188 
Constipation, 473 

cannon-ball massage for, 476 
causes of, 474 
dietary hints for, 474 
exercise for, 471, 477 
Graham on massage for, 476 
Jueltner on, 477 
massage for, 471, 475 
outdoor exercise for, 477 
Savage on, 477 

Zander machines for, 476, 477 
Correct posture for school children, 217 
Correspondence schools of exercise, 88 

systems of, 89 
Corset, bad, 396 

good, 397 
Couberton introduces athletics into 

French schools, 148 
Crampton's elevation cues to correct 
posture, 226 
test for athletic condition, 43 
for blood-pressure, 43 
Criminals, experiment on, 317 
mental training for, 318 



Criminals, physical training for, 317 

Wey on, 317 
Cromie on daily health exercises, 91 

on weight loss during exercise, 68 
Curtain-ball game, Sargent's, 81 

Dalcroze, eurythmic gymnastics of, 
137, 281 
Ufe of, 137 
Dancing for feeble-minded, 313 

in municipal playgrounds, 207 
Darwin's description of facies of rage, 20 
Dead line of age in exercise, 78 
Deaf-mutes, Green's experiments on, 300 
importance of learning articulation, 

300 
Up-reading by, 298 
low lung capacity of, 297 
Mt. Airy Institution for, 298 
physical education of, 286, 296 
setting-up exercises for, 299 
Decathlon, indoor, of Y. M. C. A. 

Athletic League, 171 
Deep breathing, experiments on, 483 
Delsarte doctrine of Hmpness, 136 
life of, 134 
sayings of, 135 
system of, 135 

Americanized form, 136 
Bishop on, 136 
Call on, 137 
self-hjqanotism by, 137 
Demeny's system of exercise, 131 
Diabetes, exercise for, 329 

Finkler on, 330 
Digestive disorders, exercise for, 471 

massage for, 471 
Dilatation of heart, Allbutt on, 45 
in exercise, 45 

Schumacker and Middleton on, 47 
Stengel on, 46 
Discus throw, 159 

distances for, 160 
Greek style, 159 
Disease, ancient use of exercise for, 320 
treatment by exercise, 334 . 
by massage, 334 



INDEX 



571 



Distance races, length of, 151 

second wind in, 151 

times for, 152 

training for, 151 
Double art of Ling, 109 
Du Bois-Reymond, 102 
Dumb-bells, 364 

Dynamometer, grip, in muscle testing, 
32 

Eberhart on vibration, 354 
Eccles on neuritis, 533 
Edinger's exhaustion theory of locomo- 
tor ataxia, 553 
Education for skill in exercise, 18 
Effleurage in massage, 341 
Effort, facial expression in, 19 
Elmira State Penitentiary, experiment 

on criminals at, 317 
Emigrants, testing of, for feeble-minded- 

ness, 307 
Endurance, exercises of, 22. See also 

Exercises of endurance 
England, revival of sports in, 144 
English ribbon dance, 236 
Equipment for municipal playgrounds, 

195, 201, 202 
Esthetic dancing, 280 
Eurythmic gymnastics of Dalcroze, 137, 
281 
basis of, 139 
description of, 140-142 
divisions of, 138 
value of, 142 
Examination, medical, of college athletes, 

263 
Excretion, control of, in exercise, 63 

increased by exercise, 70 
Excursions for playgrounds, 213 
Exercise, active, 17 

blood-supply required in, 35 
age in, 73 

albuminuria after, 70 
application to pathologic conditions, 

320 
behavior of lungs during, 30 
of muscles during, 30 



Exercise, brisk, during school hours, 220 
by sinusoidal current, 362 
choice of, factors regulating, 83 
control of excretion in, 63 

of movement in, 63 

of nutrition in, 63 
correspondence schools of, 88 
dead line of age in, 78 
Demeny's system of, 131 
dilatation of heart in, 45 
during menstruation 278, 279 
education for skill in, 18 
effects of, on childbirth, 279 

on heart, 45, 50 
in age, 55 
in youth, 55 
fever after, 71 

for child, three objects of, 214 
for city dwellers, 87 
gain of weight after, 68 
graded, for college men, 247 
Hawke's experiments on blood-count 

after, 34 
heart murmurs after, 48 
in age, regulation of, 54 
in natural occupations of man, 87 
increase of excretion from, 70 
loss of weight during, 68 
mechanical, 352 
occupation in, 73, 87 
passive, 17. See also Passive exercise 
regular, for infant, 73 
rhythm in, 137 
severe, nephritis from, 72 
sex in, 73 

sudden stopping of, dangers from, 62 
tabloid, for busy man, 90 
treatment of abdominal weakness by, 
459, 466-469 

of arteriosclerosis by, 498 

of circulatory diseases by, 493 

of club-foot by, 371 

of constipation by, 471, 477 

of diabetes by, 330 

of digestive disorders by, 471 

of disease by, 320, 334 

of flat-foot by, 371, 377 



572 



INDEX 



Exercise, treatment of gout by, 329 

of inebriety by, 335 

of obesity by, 527 

of pulmonary tuberculosis by, 330, 
481, 484, 487 

of respiratory diseases by, 479 

of scoliosis by, 438, 450 

of sprains by, 331 

of talipes by, 386 

of uneven shoulders by, 412-414 

of visceroptosis by, 471 
violent, effects of, on heart, 57 

in later life, 47 
year's course of, at University of 

Pennsylvania, 259 
Exercises, adaptation of, 65 
beginning, for blind, 287 
best, at age of eighteen, 84 

for mature age, 85 
brief, for daily use, 91-94 
classification of, 17, 79-81 
corrective, for blind, 288 
during school hours, 218 
educational, for feeble-minded, 311 
for longevity, 86 
free, 364 

gymnastic, classification of, 82, 83 
of childhood, 74 
of effort, 18 

effect on circulation, 50 

effects of, 29 

entire muscular system taking part 
in, 19 

neuromuscular education by, 32 

qualities cultivated by, 22 
of endurance, 22, 328 

effects of, 29, 53 

for development of heart, 52 

influence on general system, 29 

mild, 21 

muscle changes from, 33 

qualities cultivated by, 23 

results of excess in, 23 
of skill for correction, 328 

in pathologic conditions, 328 
of speed, strain on heart in, 52 
of strength after operations, 321 



Exercises of strength, hanging position 
in, 323 
in pathologic conditions, 321 
kneeling position in, 323 
leg movements in, 326 
list of, 322 

lying position in, 323 
positions of arms in, 323, 324 

of trunk in, 326 
sitting position in, 323 
strain on heart in, 52 
trunk movements in lying position, 
326 
Plato's classification of, 17 
spontaneous, of infant, 72 
Exertion, severe, changes in heart 

muscle from, 33 
Exhaustion, 28 
danger of, 78 
facial expression of, 27 
Exner introduces physical training in 
China, 166 

Facial expression in breathlessness, 23 
in effort, 19 
in exhaustion, 27 
in fatigue, 25, 26 
in rage, 20 
Falsetto voice, Clark's treatment of, 540 
Far Eastern Olympic Games of Y. M. 

C.A, 173 
Fatigue, 23 
chronic, 28 

recovery from, 28 
facial expression in, 25, 26 
scoliosis from, 422 
subacute, 28 
Faught's sphygmomanometer, 41, 42 
Faulty postures of school children, 216 
Feeble-minded, Barr on, 311 
dancing for, 313 
divisions of, 305 
educational exercises for, 311 
institutional treatment for, 311 
military drill for, 312 
out-door sports for, 313 
Tadd on, 313 



INDEX 



573 



Feeble-minded, training co-ordination 

in, 312 
Feeble-mindedness, Fernald on, 311 

Healy's frame test for, 307 

Knox's test for, 307 

Seguin form board test for, 307 

testing emigrants for, 307 
Fellenberg, 95 
Fencing at West Point, 256 
Fernald on feeble-mindedness, 311 
Fever after exercise, 72 
Field athletics, events of, 150 
Finger machine, Sargent's, 368 
Finkler on diabetes, 330 
Fitz on cause of scoliosis, 423 
Flat-foot, 371 

causes of, 374, 375 

diagnosis of, 374 

diflferential diagnosis of, 377 

ground-gripper shoe for, 383 

in hospital nurses, 375 

making print of foot in, 376 

Ochsner's bandage for, 384 

Roth on, 375 

Small's shoe for, 383 

symptoms of, 375 

Thomas heel for, 383 

treatment by exercise, 377 

Whitman's plate for, 384 
Follen, 104 

Foot, arrangement of bony structure, 371 
Football, modified, for blind, 293 
Foot-racing for blind, appliance for, 292 
Forbes' rotation treatment of scoliosis, 

458 
Fractures, massage for, 333 
France adopts Swedish system, 129 

introduces athletic sports into school 
system, 129 

revives athletics, 129 
Franklin on out-door sleeping, 492 

on physical education in colleges, 240 
Frenkel's colored swinging balls, 561 

notched board, 559 

perforated board, 561 

triangle block, 560 
Friction in massage, 342 



Friesen, 96 

Froebel on physical evolution, 76 
Fun Field playground, 194 
Fundamental movements, 63 

Galbraith on physical education of 

women, 271 
Galen on massage, 31 
Games, athletic, classification of, 79-81 
during school hours, 219 
gymnastic, classification, 82 
of boyhood, periods for, 75 
of childhood, 74 
special, for recess periods, 222 
with specific purpose, value of, 81 
Gang instinct in boys, 76 
Garber adjustable school desk, 215, 216 
Gastritis, massage for, 478 
Gefahrenskala, 62 
Georgii, 112 
German system, 95 

American adaptation of, 107 
and Swedish system compared, 123 
hiistory of, 95 
in American colleges, 241 
in schools, 229 
mass work of, 100 
outdoor games in, 103 
Stecher's divisions of, 105 
Y. M. C. A. adaptation of, 170 
Giraudet, pupil of Delsarte, 134 
Girl and boy, difference in development 

of, 271 
Girls, Camp-fire, 179 
physical evolution of, 76 
schools for, physical education in, 270 
Glen Mills Industrial School for in- 

corrigibles, 315 
Goddard's revision of Binet-Simon 

measuring scale, 306 
Goldthwait splint for visceroptosis, 472 

straps for round shoulders, 407 
Gordon on hypertrophy of heart, 54 
Gorilla posture, 225 
Gould on causes of scoliosis, 421 
Gout, exercise for, 329 
Graham on arthritis deformans, 334 



574 



INDEX 



Graham on massage for constipation, 
476 

on neuritis, 534 
Granville's percutor, 533 
Green's experiments on deaf-mutes, 300 
Greenwood on round shoulders, 390 
Grenville on vibration, 352 
Griesbach on mental fatigue in Swedish 

gymnastics, 66 
Ground-gripper shoe for flat-foot, 383 
Group games, development of, 143 
Gulick, founder of Camp-fire Girls, 182 
of New York School Athletic 
League, 231 

in Y. M. C. A. work, 165 

on daily exercise for busy man, 91 

on gang instinct, 76 

chart of boys' games, 75 
Guts-Muths, 95-97 
Gymnasium costume for women, 285 
G3Tnnasiums for schools, 229 
Gymnastic apparatus, original uses for, 
82 

games for women, 282 
Gymnastics, age of introduction, 77 

eurythmic, of Dalcroze, 137 

for incorrigibles, 315 

German system of, 95 

Swedish system of, 108 

Hamilton Park recreation center, 205 
Hammer, description of, 160 
throw, accidents from, 161 
distances for, 161 
origin of, 160 
Hammett's observations on ex-distance 

runners, 61 
Hamstrings, pulling, 31 
Hanging position in exercises of strength, 

323 
Hare and hounds, 153 
Hartelius, 112 

Hartwell on Swedish system, 115 
Harvey on abdominal hernia, 460 
Hawke's experiments on blood-count, 

34 
Headache, massage for, 531 



Healey's frame test for feeble-minded- 

ness, 307 
Heart after exercise, Selig on, 56 

after rowing, Lehrbecher on, 57 

after wrestling, Schott on, 57 

capacity, effect of exercise on, 45 

dilatation of, in exercise, 45 

diseases, table of blood-pressure 
changes in, 495 

effects of exercise on, 50, 57 
in later life, 47 

efficiency, estimation of, 39 

growth in adolescence, 54 

in ex-athletes, 59 

murmur, Ayer and McKenzie on, 48 
after exercise, 48 

physiologic hypertrophy of, 49 

reflex of contraction, 346 

Riviere's observations in boys', 55 

strain on, in exercises of speed, 52 
of strength, 52 

Zuntz on effects of mountain-climbing 
on, 55 
Heart-muscle, changes in, from severe 

exertion, 2^ 
Heineman on Schott treatment, 519 
Hematuria in Marathon runners, 71 
High jump, 157 

distances for, 157 
High-school pupils, physical defects in, 
228 
postural defects in, 228 
Hill's inhalation experiments, 35, 37 
Hippocrates on untrained body, 72 
Hitchcock's vital statistics of college 

men, 241 
Hofbauer apparatus for emphysema and 

asthma, 491 
Hooker, first professor of physical educa- 
tion, 241 
Horizontal bar, 107 
Hurdle-races, distances for, 153 

height of hurdles in, 153, 154 

regulations of, 154 

times for, 154 
Hypertrophy of heart, Gordon on, 54 
physiologic, 49 



INDEX 



575 



Idiots, 305 

Imbeciles, 305 

Imbecility, Knox's test of, 307 

Inco-ordination in mental deficients, 304 

Incorrigibles, Glen Mills School for, 315 

gymnastics for, 315 

military drill for, 315 

outdoor sports for, 315 

physical training for, 314 
Inebriates, Colles on exercise for, 335 
Infant, muscular work done by, 74 

regular exercise for, 73 

spontaneous exercises of, 73 
Infantile paralysis, scoliosis from, 454 
Inhalation experiments of Hill, 35, 37 
Inomotor, Sargent's, 370 
Institutional treatment for feeble- 
minded, 311 
Intercollegiate Games, First American, 

144 
Intercostal machine, 406 
International Federation of Sports, 149 

Olympic Committee, founding of, 149 

Jackson, levels of, 84 

Jahn, 95 

opens first Turnplatz, 96 

Japanese torpedo game for blind, 290 

Javelin throw, 158 
distances for, 158 

Jefferson on physical education in col- 
leges, 241 

John Dickinson playground, 186 

Jueltner on constipation, 477 

Juvenile delinquency, study of, 192 

Kellogg on arteriosclerosis, 498 

sinusoidal current treatment of obe- 
sity, 527 
vibrator, 357 
Key-note position in scoliosis, 437 
Kinghorn on exercise in tuberculosis, 482 
Knee injuries, Broad on massage for, 2^2 
Kneeling position in exercises of strength, 

323 
Knox's imbecile test, 307 
moron test, 307 



Korykos of Athenians, 146 
Kraenzlein, 103 

Kraus on competitive sport, 62 
Kyphosis, 390 

Lauder Brunton on blood-pressure, 42 
Leaders' Club of Y. M. C. A., 171 
L'Ecole Monge, 129 
Lee on municipal playgrounds, 188 
Leg movements in exercises of strength, 

325 
Lehrbecher on heart after rowing, 57 
Levels of Hughlings Jackson, 84 
Lewis' new gymnastics for women, 275 

Phonometric Institute, 543 
Lieber, 99 
Ling (Peter), double art of, 109 

founder of Swedish system, 108 
on massage, 337 , 
succeeded by Branting, in 
(Hjalmar), 112 
succeeded by Torngren, 113 
Lip-reading in deaf-mutes, 298 
Locomotor ataxia, causes of, 553 

Edinger's exhaustion theory of, 553 
exercise treatment of, 555 
Frenkel's colored swinging balls in, 
561 
notched board in, 559 
perforated board in, 561 
triangle block in, 560 
Maloney's treatment of, 562. 
Mitchell's treatment of, 562 
. prognosis in, 565 

Romberg's symptom in, 554 
routine of treatment in, 564 
symptoms of, 554 
typical cases of, 565 
von Leyden's stairway in, 556, 557 
ten-pin arrangement in, 559 
Lomi-lomi, 336 
London Athletic Club, 144 

municipal playgrounds of, 186 
Longevity, exercises for, 86 
Lovett apparatus for round shoulders, 
391, 408 
on round shoulders, 390 



576 



INDEX 



Lovett stretching board for structural 

scoliosis, 456 
Lungs, behavior of, during exercise, 30 

low capacity of, in deaf-mutes, 297 
Lying position in exercises of strength, 

323 

Mackaye, disciple of Delsarte, 135 
Maggiora on massage, 338 
Makuen on stammering, 542 
JSIaloney's treatment of locomotor 

ataxia, 562 
Marathon race dangerous for boys, 153 
revival of, 152 
training for, 153 

runners, albuminuria in, 71 
hematuria in, 71 
Mass work of German system, 100 
Massage, best time for, 348 

contraindications for, 351 

derivation of word, 336 

effect on muscles, 339 

effleurage in, 341 

for arteriosclerosis, 498 

for arthritis deformans, 334 

for athletes, 340 

for chorea, 545 

for constipation, 471, 475 

for digestive disorders, 471 

for fractures, S33 

for gastritis, 478 

for headache, 531 

for infantile paralysis, 551 

for knee injuries, Broad on, 332 

for neuralgia, 532 

for neurasthenia, 537 

for obesity, 529 

for occupation palsies, 534 

for old sprains, 332 

for rheumatism, 333, 534 

for special organs, 349 

for sprains,. 331 

for visceroptosis, 471 

friction in, 342 

Galen on, 31 

general, order of, 348 

history of, 336 



Massage in rest cure of Weir Mitchell, 

333 

Ling on, 337, 341 

lubricants in, 350 

Maggiora on, 338 

mechanical, 352 

Mitchell's experiments on blood-count 
after, 34 

Mosso on, 338 

percussion in, 344 

petrissage in, 343 

pinching in, 343 

Randall on, 350 

running nerve friction in, 347 

stroking in, 341 

Swedish system of, 337 

tapotement in, 344 

treatment of disease by, 334 

vibration in, 346 

Weir Mitchell on, 349 

Zabludowski on, 350 
Masseur, knowledge of anatomy for, 337 

physical requirements of, 337 
Mature age, best exercises for, 85 
McCurdy on blood-pressure, 51 

experiments on proteins by, 69 
McKenzie and Ayer on heart murmur, 
48 

scoliosiometer of, 430 
Measurements of typical college athlete, 

269 
Mechanical exercise, 352 

massage, 352 
Medical examination before Y. M. C. A. 

instruction, 167 
Medicine ball, 1 70 

Menstruation, exercise during, 278, 279 
Mental defectives, inco-ordination in, 

304 
phj'-sical education of, 302 

examination of, 305 
Warner on, 302 
deficiency, Binet-Simon measuring 
scale for, 306 
sj'mptoms of, 303 
fatigue in Swedish gjTnnastics, 66 
training for criminals, 31S 



INDEX 



577 



Meylan on pulse-rate, 39 

experiments on pulse-rate in training 

by, 39 

observations on ex-oarsmen by, 60 

summer camp, 177 
Middleton and Schumacker on dilatation 

of heart, 47 
Military drill for feeble-minded, 312 

for incorrigible, 315 
Mills' treatment of aphasia, 540 
Mind, presence of, 65 
Mitchell on blood-count, 34 

experiments on blood-count after 
massage by, 34 

treatment of locomotor ataxia, 562 
Moral defectives, physical education of, 

302 
Morgan's observations on ex-oarsmen, 

59 
Morons, 305 

Knox's test of, 307 
Mosher on exercise during menstruation, 
278 
postures in standing, 223, 224 
Mosso on massage, 338 

plethysmograph, 33 
Motor dullards, characteristics of, 307 
Movement, control of, in exercise, 63 
Mt. Airy Institution for Deaf and Dumb, 

298 
Miiller on fifteen-minute health exer- 
cises, 91 
Municipal bath-houses, 212 
baths, 184 
playgrounds, 184 

arguments in favor of, 190 
athletic exhibitions of, 210 
Bancroft on games for, 206 
Burns on, 192 

care of swimming pool, 212 
competitive sports for, 209 
concentric circle plan of, 188 
dancing in, 207 
day's program for, 205 
divisions of, 194 
evils from lack of, 191, 192 
excursions for, 213 
37 



Municipal playgrounds, equipment for 
boys and young men, 202 
for girls and small boys, 202 
good accomplished by, 213 
importance of supervision, 213 
in Boston, 186 
in London, 186 
in Philadelphia, 186 
in school yards, 199 
in Stockholm, 185 
large, facilities of, 203 
Lee on, 188 
medium, equipment for, 196-199 

Hanmer's equipment for, 201 
organized games for, 208 
patriotic celebrations for, 210 
seasonal games for, 208 
small, ecjuipment for, 195 
story books for, 206 
supervisors of, 203 . 

courses of instruction for, 203 
swimming instruction for, 210 
swimming-pool regulations, 212 
value to foreign population, 194 
Murray, successor to Torngren, 113 
Muscle changes from exercises of endur- 
ance, :is 
soreness, causes of, 30, 31 
testing by grip dynamometer, 32 
tonus, 30 
Muscles, behavior of, during exercise, 30 
beneficial effects of passive exercise on, 

33 
of training on, 35 
effect of massage on, 339 
of elimination, 69 
Muscular action, by-products of, 70 
contraction, effect of carbon dioxid on, 

38 
development and co-ordination, possi- 
bilities of, 64 
power, Storey's observations on, 33 
work done by infant, 74 

Nachtegall, 96 

Narragansett pulley-weight, 366 

Nautical wheel, 369 



578 



INDEX 



Nephritis from severe exercise, 72 
Nervous dyspepsia, Weir Mitchell's rest 

cure for, 478 
Neuralgia, Granville's percutor for, 532 
massage for, 532 
vibration for, 532 
Neurasthenia, massage for, 537 
outdoor exercise for, 538 
Weir-Mitchell's rest treatment for, 537 
Neuritis, Eccles on, 533 
Graham on, 534 
vibration for, 533 
Neuromuscular education by exercises 

of effort, 32 
New Gymnastic High School at Stock- 
holm, 126 
New York Public School Athletic 
League, 231 
athletic fields of, 238 

meets of, 232 
competitive tests of, 233 
girls' branch of, 236 
rifle meets of, 235 
target practice in, 233 
Schools, day's order in, 229 
Night, loss of weight during, 69 
Normal urine, albumin in, 70 
Nutrition, control of, in exercise, 63 
Nyblaeus, successor to Branting, 112 

Obesity, Bergonie's electric treatment 
of, 526 

causes of, 520 

complications of, 523 

dangers in reduction treatment of, 530 

diet regulation in, 525 

examination in, 522 

exercises in, 527 

general, 522 

heredity in, 520 

Kellogg's sinusoidal current treat- 
ment, 527 

localized, 521 

massage in, 529 

prognosis in, 522 

reduction cures in, 524 

regulation of habits in, 526 



Obesity, restriction of liquids in, 525 
thyroid extract in, 529 
typical cases of, 530 

Occupation in exercise, 73, 87 
palsies, massage for, 534 

Ochsner's bandage for flat-foot, 384 

Oertel's walking exercises in arterio- 
sclerosis, 497 

Olympic Games in Berlin in 1916, 103 

One-year residence rule, 264 

Operator, personality of, in passive ex- 
ercise, 335 

Oppenheim's inhibition gymnastics for 
tic, 539 

Orton's summer camp, 177 

Outdoor apparatus for blind, 289 

athletic tests of Athletic League of 

Y. M. C. A., 172 
athletics under cover, 259 
exercise for neurasthenia, 538 
for women, 283 
necessary for city children, 88 
games in German system, 103 
sleeping, Franklin on, 492 
sports for feeble-minded, 313 
for incorrigibles, 315 

Overbrook School for the Blind, 287 

Overstrain, danger of, 78 

Overtraining, 66, 67 
recovery from, 28 

Oxygen, effects of, after walking, 37 
inhalation. Hill's experiments on, 35 

Paidotribes, 336 
Pancratum of Spartans, 145 
Pantograph method of recording sco- 
liosis, 429 
Paper chases, 153 
Parallel bars, 107 

Sargent's traveling, 369 
Paralysis, infantile, deformities in, 547 

from anterior poliomyelitis, 546 

illustrative case of, 552 

massage for, 551 

prognosis in, 552 

reconstruction treatment of, 550 

table of distribution of,. 546 



INDEX 



579 



Paralysis, infantile, vibration for, 551 
Parry on exercise during menstruation, 

279 
Passive exercise, 17 

beneficial effect on muscles, 33 
personality of operator in, 335 
role of, 67 
uses of, 29 

in tuberculosis, 488-490 
movements, 336 

for arthritis deformans, 334 
for rheumatism, 333 
treatment by, 330 
Patriotic celebrations for playgrounds, 

210 
Pentathlon of Athenians, 148 

of Y. M. C. A. Athletic League, 171 
Percussion in massage, 344 
Percutor of Grenville, 352 
Personality of operator in passive exer- 
cise, 335 
Pescher spirometer, 490 
Pestalozzi, 95 
Petrissage, 343 

Philadelphia Municipal Board of Recre- 
ation founded, 187 
municipal playgrounds, 186 
Playground Association founded, 186 

summer camps of, 175, 178 
schools, recreation drills in, 229 
Philanthropinum of Basedow, 95 
Physical confidence, cultivation of, in 
blind, 288 
defects in high school pupils, 228 

in college women, 277 
degeneracy from city life, 184 
education by athletics, 143 
by Y. M. C. A., 164 
courses for teachers of, 231 
first college chair of, 241 
German system of, 95 
in colleges, 240 
best forms of, 248 
compulsory, 244 
courses on theory of, 266 
development of, 244 
elective, 251 



Physical education in colleges, fencing 
in, 256 

Franklin on, 240 

functions of director of, 265 

Jefferson on, 241 

physical examination before, 245 

requirements for director of, 265 

student class leaders in, 265 

wrestling in, 256 
in girls' schools, 270 
in schools, 214 
disciplinary value of, 228 
necessity of, 228 
in smaller colleges, 251 
in women's colleges, 270 
introduced in China, 166 
of Athenians, 146 
of blind, 286 

compulsory, 289 

girls, 296 
of criminals, 317 
of deaf-mutes, 286, 296 
of incorrigibles, 314 
of mental defectives, 302 
of moral defectives, 302 
of Spartans, 145 
of women, archery in, 284 

at Vassar, 284 

Ballentine on, 274 

bowling in, 284 

competitive athletics in, 283 

costume for, 285 

division into groups for, 280 

early provisions for, 274 

esthetic dancing in, 280 

eurythmic gymnastics for, 281 

Galbraith on, 271 

gymnastic games in, 282 

introduction of games for, 275 

Lewis' new gymnastics for, 275 

on apparatus, 282 

outdoor exercise in, 283 

physical examination before, 276 

quoits in, 284 

separate system for, 270 

supervision of rest in, 285 

swimming in, 284 



S8o 



INDEX 



Physical education of women, team 
games in, 270 
opportunities for research in de- 
partment of, 268 
svmimer college courses in, 267 
endurance of men and women, com- 
parison of, 273 
evolution of boys, 76 

of girls, 76 
examination of college men, 245 
analysis of, 246 
Storey on, 245 
of women before physical education, 
276 
athletes, 278 
method of, 277 
ideal, search for, 269 
intelligence, cultivation of, 248 
superiority of civilized man, 248 
Pilgrim on vibration, 354 
Pinching in massage, 343 
Plato's classification of exercise, 17 
Play instinct, direction of, 143 
Playgrounds, municipal, 184. See also 

Municipal playgrounds 
Plethysmograph, Mosso's, 33 
Pole vault, 157 

distances for, 158 
regulations of, 158 
Poliomyelitis, anterior, infantile, paral- 
ysis from, 546 
Polymachinon of Chiosso, 365 
Pool on exercises of strength after opera- 
tions, 321 
Population, depletion of, in rural dis- 
tricts, 184 
Positions in exercises of strength, 322 
of arms in exercises of strength, 323, 

324 
of trunk in exercises of strength, 326 
Posse, 113 
Postural defects in high-school pupils, 

228 
Posture, bad, bantam tjqje, 225 
gorilla type, 225 
round back, 225 
sunken chest, 227 



Posture, bad, tests for, 224 
vertical line test of, 225 

correct, 226, 227 

Crampton's elevation cues to, 226 

tests, good results from, 228 
Postures in standing, Mosher's, 223, 224 
Presence of mind, 65 
Prevention of accidents to blind, 288 
Professional, Y. M. C. A. Athletic 

League definition of, 172 
Pulley-weight, Narragansett, 366 

of Sargent, 366 
Pulling of hamstrings, 31 
Pulmonary tuberculosis, exercise for, 330 
Pulse-rate, effect of exercises of endur- 
ance on, 53 

in staleness, 39 

in training, 39 

Meylan on, 39 

normal, 39 

Quoits for women, 284 

Rage, facial expression in, 20 

Randall on massage, 350 

Recess periods during school hours, 220 

special games for, 222 
Recreation drills in Philadelphia schools, 
229 
places a necessity for city dwellers, 88 
Reduction cures in obesity, 524 

dangers of, 530 
Respiratory diseases, treatment of, by 
exercise, 479 
madness, 36 
Rest cure of Weir Mitchell, massage in, 

333 

Reynolds on round shoulders, 390 

Rheumatism, massage for, 333, 534 
passive movements for, 333 
vibration for, 333 

Rhythm in exercise, 137 

Rhythmic exercises for backward chil- 
dren, 310 

Rickets in scoliosis, 427 

Riviere's observations on heart in boys, 
55 



INDEX 



581 



Roberts' system of exercise in Y. M. C. 

A. work, 165 
Romberg's sjinptom in locomotor ataxia, 

554 
Rope climbing, 254 

Rosenthal on tuberculous pleurisy, 491 
Roth, 112 
method of recording in scoliosis, 429 
on flat-foot, 375 
on occurrence of scoliosis, 426 
pupil of Ling, 112 
Rothstein, loi, iii 

Round back, measurements for deter- 
mining, 391 
posture, 225 
shoulders, Bancroft on, 396 
webbing for, 408 
causes of, 392 

examination of back in, 394 
exercises for, 399-404 
frequency of, 393 
Goldthwait straps for, 407 
Greenwood on, 390 
hygienic treatment for, 395 
intercostal machine for, 406 
Lovett's apparatus for, 408 

for determining, 391 
prognosis in, 395 
Reynolds and Lovett on, 390 
Taylor's spinal assistant for, 406 
treatment of, 399 
Zander's tower for, 406 
Rowing, Lehrbecher on heart after, 57 
Royal Central Gymnastic Institute, 

lOI 

Rubber ball game for blind, 291 
Rubner on competitive sport, 62 
Rugby Crick Run, 144 
Running, long-distance, 28 

nerve friction in massage, 347 

track, construction of, 149 
Rural districts, depletion of population 

in, 184 
Russell Court playground, 186 

Salzman, 95 

Sargent's curtain-baU game, 81 



Sargent's finger machine, 368 

inomotor, 370 

pulley-weight, 366 

traveling parallel bars, 369 

vital statistics of college men, 244 
Satterthwaite's modification of Schott 

treatment, 517, 518 
Savage and Barach on urine of Marathon 
runners, 71 

on constipation, 477 

on effects of violent exercise on heart, 

57 
Schaffer's method of artificial respira- 
tion, 35 
Scholastic standing of college athletes, 

263, 264 
Scholder on occurrence of scdUosis, 

426 
School children, chorea in, 544 

correct posture for, 217 

faulty postures of, 216 

stammering in, 541 
desk, Garber adjustable, 215, 216 

proper, 215 

rules for construction of, 437 

Scudder on, 215 

Stecher on, 215 
games, Worden on, 223 
gymnasiimis, 229 

arrangement of, 230 

equipment for, 230 

exercises during, 218, 220, 223 

games during, 218 

recess periods during, 220 ~ 
playgrounds, 199 

size requirements of, 231 

urgent need for, 231 
rooms, hygienic, dimensions of, 214 

proper arrangement of, 215 
desks for, 215 
German system in, 229 
physical education in, 214 

necessity of, 228 
Swedish system in, 229 
Schott on heart after wrestling, 57 
treatment, exercises illustrated, 504- 

516 



582 



INDEX 



Schott treatment for arteriosclerosis, 
502 
Heineman on, 519 
Satterthwaite's modification, 517, 

518 
Thome on, 503 
Schulthess apparatus for recording 

scoliosis, 429 
Schumacker and Middleton on dilata- 
tion of heart, 47 
Schwann's law of muscular contraction, 

363 
Scissors jump, 157 
Scoliosiometer, McKenzie's, 430 
Scoliosis, 390 
Brackett on, 424 
causes of, 421 
C-shaped curve in, 422 
diagnosis of, 428, 432 
exercises for, 438, 450 
family occurrence of, 427 
Fitz on cause of, 423 
frequency of, 425 
from bad sleeping posture, 424 
from fatigue, 422 
from faulty writing posture, 436 
from infantile paralysis, 454 
from poor lighting of schoolrooms, 437 
Gould on causes of, 421 
in school children, 426 
key-note position in, 439 
McKenzie's instrument for recording, 

430 
natural defences against, 416 
prognosis in, 434 
right dorsal and left lumbar, exercises 

for, 450 
Roth on occurrence of, 426 

method of recording, 429 
Scholder on occurrence of, 426 
Schulthess apparatus for recording, 

429 
signs of rickets in, 427 
Spellissy's method of photography in, 

429 
structural, Lovett stretching board 

for, 456 



Scoliosis, structural, symptoms of, 433 
treatment of, 456 

total left, exercises for, 443 

treatment of, 435 

by Abbott's apparatus, 458 
corrective, 438 
Forbes' rotation, 458 

typical cases of, 448, 453-455 
Scripture's melody cure of tic, 540 
Scudder on school seating, 215 
Seaver flat truss pad, 464 
Second wind, 24, 36, 151 
Seguin form board test for feeble- 
mindedness, 307 
Self-hypnotism by Delsarte, 137 
Selig on heart after exercise, 56 
Sensorial gymnastics for backward 

children, 309 
Seton Indians, 179 

Setting-up exercises for deaf-mutes, 299 
Sex in exercise, 73 
Shot-put, 162 

distances for, 163 

regulations of, 163 
Sinusoidal current, exercise by, 360 
Sitting position in exercises of strength, 

323 
Skill, acquirement of, 63 

in exercise, education for, 18 
Small's shoe for flat-foot, 383 
Spartans, physical education of, 145 
Special schools for backward children, 

309 
Spellissy's method of photography in 

scoliosis, 428 
Sphygmomanometer, Faught's, 41, 42 
Spiess, 95, loi 
Spondylotherapy, 345 
Sports, athletic, 143 

Bartsch's danger scale for, 62 
Sprains, exercise for, 331 

massage for, 331 
old, 332 
Springfield Y. M. C. A. Training School, 

Sprint races, distances of, 150 
times for, i ^^o 



INDEX 



583 



Sprint races, training for, 150 
Staleness, 23, 66, 67 

pulse-rate in, 39 
Stammering in school children, 541 

Makuen on, 542 

mechanism of, 542 

treatment of, 543 
Stamp on blood-pressure, 51 
Stebbins, disciple of Delsarte, 135 
Stecher on school seating, 215 

divisions of German system by, 105 
Stengel on dilatation of heart, 46 
Stockholm, municipal playgrounds in, 

185 
Stokes on arteriosclerosis, 499 

on danger of prolonged training, 61 
Storey on physical examination of 
college men, 245 

observations on muscular power by, 

33 
Stroking in massage, 341 
Subtarget machine, 233 
Summer camp, athletic instruction in, 
177 
day's program in, 177 
elements of success for, 175 
medical supervision of, 176 
Meylan's, 177 
Orton's, 177 
quarters for, 176 
site for, 176 
camps, good work done by, 178 

of Philadelphia Playgrounds Asso- 
ciation, 17s, 178 
ofY. M. C. A., 17s 
Supervision of rest in women's colleges, 

285 
Swamp Poodles, 193 
Swedish system of gymnastics, 108 
adoption by France, 129 
advantages of, 124 
and German system compared, 

123 
apparatus used in, 123 
criticism of, 124 
day's order in, 115 
distinguishing points of, 116 



Swedish system of gymnastics, divisions 
of day's order in, 116, 117, 
120 
for blind, 290 
history of, 1 08-1 11 
in schools, 229 
introduced into United States, 

113 
mental fatigue in, 66 
modern deviations from, 126 
Y. M. C. A. adaptation of, 170 
of massage, 337 
Swimming for blind, 293 
for women, 284 
instruction in playgrounds, 210 
pool for college gymnasium, 258 
Systolic pressure, Brunton's observa- 
tions on, 42 

Tabloid exercise for busy man, 90 

Tadd on feeble-minded, 313 

Talipes, exercises for, 386-388 

Tapotement, 344 

Taylor's spinal assistant, 406 

Techow, III 

Temperature, normal, fluctuation of, 72 

Therapeutic wastefulness of athletic 

games, 81 
Thomas heel for flat-foot, 383 
Thompson Seton and Seton Indians, 179 
Thorne on Schott methods of treatment, 

503 
Thyroid extract in obesity, 529 
Tic, Oppenheim's inhibition gymnastics 
for, 539 
Scripture's melody cure of, 540 
treatment of special forms of, 540 
To rngren, successor to Hjalmar Ling, 113 
Track athletics, events of, 150 

for blind, 293 
Training, beneficial effects on muscles, 

35 
danger of prolonged, 61 
for distance races, 151 
for sprint races, 150 
Hippocrates on, 72 
pulse-rate in, 39 



584 



INDEX 



Training, pulse-rate in, Meylan's experi- 
ments on, 39 

purposes of, 67 

table for college athletes, 263 

Weyman on blood-pressure in, 44 
Triple test for bad posture, 224 
Trunk movements in lying position in 

exercises of strength, 326 
Treatment by passive movements, 330 

exercises of endurance in, 329 
of skill in, 327 

of disease by exercise, 334 
by massage, 334 
Tuberculosis, breathing exercises in, 481 

Butler on, 491 

danger from athletics in, 480 

detection of, in college students, 479 

enforced deep breathing in, 483 

exercises in, 481, 484-487 
passive, 488-490 

Kinghorn on exercise in, 482 

Pescher spirometer in, 490 

pleural, Rosenthal on, 491 

regular routine in, 481 

Zander apparatus in, 490 
Turnfests, 99 

of Frankfort and Leipsic, 100 
Turngemeinden, American, 105 
Turning, revival of, in Germany, 97 
Turnkunst, 97 
Turnplatz, Jahn's first, 96 
Turnvereins, 99 
T3T)ical college athlete, measurements 

of, 269 

Underexercise, civilization a factor 

in, 88 
Uneven shoulders, causes of, 411 
exercises for, 412-414 
frequency of, 411 
prognosis in, 415 
Universities, physical education in, 240 
University of Pennsylvania, athletic 
pageants at, 260 
scale for swimmers at, 254 
for track athletes at, 252 
table of athletics at, 262 



University of Pennsylvania, year's 
course of exercise at, 259 

Van de Walker on blind, 292 
Vassar, athletic program at, 284 
Vaulting horse, 107 
Vertical line test for bad posture, 225 
Vibration, Eberhart on, 354 

effects of, 358 

for arthritis deformans, 334 

for infantile paralysis, 551 

for neuralgia, 532 

for neuritis, 533 

for rheumatism, 333 

Grenville on, 352 

helmet of Boudet, 353 

in massage, 346 

movements in, 355 

Pilgrim on, 355 

Vigoroux on, 353 
Vibrator, Kellogg's, 357 

points in use of, 354 

rate of operation, 357 

Zander, 353 
Vigoroux on vibration, 353 
Virchow, 102 
Visceroptosis, exercise for, 471 

Goldthwait splint for, 472 

massage for, 471 

treatment of, 473 
Vital statistics of college men, Hitch- 
cock's, 241 
Sargent's, 244 
Von Leyden's stairway, 557 

ten-pin arrangement, 559 
von Schenkendorff, 103 

Walking, benefit of increased speed in, 77 

competitive, 153 

effects of oxygen after, 37 

for blind, 292 
Warner on mental defectives, 302 
Weber on exercises for longevity, 86 
Weight, gain of, after exercise, 68 

loss during exercise, 68 
during night, 69 

throw, fifty-six pound, 161 



INDEX 



585 



Weight throw, exercise value of, 162 
Weir Mitchell on massage, 349 

rest cure for nervous dyspepsia, 478 

for neurasthenia, 537 

massage in, 333 
West Point, fencing at, 256 
Weston, Edward Payson, 68 
Wey on criminals, 317 
Weyman on blood-pressure in training, 

44 
Whitman's plate for flat-foot, 383 
Woman, proportions of, at maturity, 271 
Women college athletes, examination of, 

278 
Women's colleges, physical education in, 

270 
Worden on school games, 223 
Wrestling, 256 

Schott on, 57 

Young Men's Christian Association, 164 
adaptation of German system, 169 

of Swedish system, 170 
Athletic League of, 171 

definition of amateur, 172 

of professional, 172 
indoor decathlon of, 171 
membership of, 172 
outdoor athletic tests of, 172, 173 
pentathlon of, 171 
campaigns of, 174 
day's order in, 170 
expansion of, 166 
Far Eastern Olympic Games of, 173 



Young Men's Christian Association, 
floating membership of, 165 

instruction, medical examination be- 
fore, 167 

Leaders' Club of, 171 

medicine ball in, 170 

physical education by, 165 

program for business men, 168 
for young men, 168 
variation of, 167 

recreation period, 170 

Roberts' system for, 165 

summer camps of, 175 

training school at Chicago, 166 
at Springfield, 165 

triangle badge of, 164 
Youth, best exercises for, 84 

effects of exercise on heart in, 55 

Zabludowski on massage, 350 
Zander apparatus for active movements, 
361 
for arteriosclerosis, 498 
for constipation, 476, 477 
for mechanical operations, 360, 362 
for passive movements, 362 
for tuberculosis, 490 
horse, 363 
Institutes, 352, 360 
orthopedic apparatus, 363 
tower, 406 
vibrator, 353 
Zuntz on effects of mountain-climbing on 
heart, 55 



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